ArticleLiterature Review

Aerobic Exercise Recommendations to Optimize Best Practices in Care After Stroke: AEROBICS 2019 Update

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Abstract

Most stroke survivors have very low levels of cardiovascular fitness, which limits mobility and leads to further physical deconditioning, increased sedentary behavior, and heightened risk of recurrent stroke. Although clinical guidelines recommend that aerobic exercise be a part of routine stroke rehabilitation, clinical uptake has been suboptimal. In 2013, an international group of stroke rehabilitation experts developed a user-friendly set of recommendations to guide screening and prescription - the Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke (AEROBICS 2013). The objective of this project was to update AEROBICS 2013 using the highest quality of evidence currently available. The first step was to conduct a comprehensive review of literature from 2012-2018 related to aerobic exercise poststroke. A working group of the original consensus panel members drafted revisions based on synthesis. An iterative process was used to achieve agreement among all panel members. Final revisions included: (1) addition of 115 new references to replace or augment those in the original AEROBICS document, (2) rewording of the original recommendations and supporting material, and (3) addition of 2 new recommendations regarding prescription. The quality of evidence from which these recommendations were derived ranged from low to high. AEROBICS 2019 Update should make it easier for clinicians to screen for, and prescribe, aerobic exercise in stroke rehabilitation. Clinical implementation will not only help to narrow the gap between evidence and practice but also reduce current variability and uncertainty regarding the role of aerobic exercise in recovery after stroke.

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... Aerobic Exercise Recommendation is more than 20 minutes that can be advised, depending on exercise frequency and intensity with a 3 to 5 minutes warm up and cool-down period. [8] There is a wide consensus that moderate to high intensity exercise aerobic training is more effective than low intensity training in the improvement cardiorespiratory fitness after stroke. Hollerand et al found in their examination that high intensity locomotion training might improve selected walking outcomes to a greater extent than low-intensity training in post-stroke individuals poststroke. ...
... Hollerand et al found in their examination that high intensity locomotion training might improve selected walking outcomes to a greater extent than low-intensity training in post-stroke individuals poststroke. [8,9] In a recently published study the validation of submaximal test (OUES) for evaluating cardiorespiratory fitness in patients with stroke have raised the need to reconsider the effectiveness of low intensity training especially in case of unconditioned patient with very low baseline cardiorespiratory capacity. The intensity connects with baseline fitness level, neurologic involvement, cardiorespiratory state and previous comorbidity. ...
... Presently despite of the fact that low intensity (<40% HRR) training is not considered as aerobic exercise [10] and the 30 minutes of moderate intensity (40%-59% HRR) aerobic exercise on most days of the week was suggested during the rehabilitation period of stroke, the low intensity was the most commonly applied intensity by physiotherapist's. [8,11] Institutional, patient-and safety-related barriers underpinned the main reasons of the gap between recommendation and practice. [11] Stroke patients have difficulties to attain the preferable intensity training because of limb dysfunction, deconditioning, fatigue low motivation, depression and associated diseases. ...
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Introduction: The purpose of our study was to evaluate the effectiveness of low-to moderate intensity aerobic training on cardiorespiratory functions in chronic unconditioned stroke patients. The oxygen uptake efficiency slope (OUES) and the ventilatory threshold (VO2-VT) could represent the aerobic capacity in submaximal test. Our study examined the application of the submaximal parameters for evaluating aerobic capacity of chronic stroke patients. Materials and methods: In our assessor-blinded controlled pilot study 37 patients were randomized into 2 groups named: intervention group (IG, n: 21) and control group (CG, n:16), respectively. Cardiorespiratory functions were evaluated by ergospirometer before and after the 4-week (20 days) program. Both groups participated in daily occupational therapy (30 minutes) and conventional, customized physiotherapy CG (60 minutes), IG (30 minutes). Only IG performed aerobic training by bicycles (30 minutes) aiming to reach low-to moderate training intensity. Outcome measures included peak oxygen uptake (VO2 peak), OUES, VO2-VT, functional exercise capacity 6-Minute Walking Test (6MWT) and Functional Independence Measure. Results: Thirty-five subjects completed the study. The VO2 peak uptake was very low in both groups (IG: 11.9 mL/kg/min, CG: 12.45 mL/kg/min) and did not improve after the program, but submaximal parameters such as VO2-VT (P < .01) and OUES (P < .001) have shown significant improvement, but only in IG regardless of insufficient impact on VO2 peak. Each participant in both groups was unable to permanently reach the moderate intensity zone. Functional Independence Measure changed for the better in both groups, but 6MWT only in the IG. Discussion and conclusions: Four-week exercise training even at low intensity by lower limb cycle ergometer may provide benefit on aerobic and functional capacity without improvement of VO2 peak on unconditioned chronic stroke patients.
... 6 The risk of an abnormal response is also increased (ie, exaggerated hypertensive response) at or near maximal exercise intensity. 7,8 Sub-maximal cardiorespiratory fitness testing is an alternative method of measuring cardiorespiratory fitness. It is recommended when exercising at moderate intensity, 7 and may be more tolerated by people with stroke. ...
... 7,8 Sub-maximal cardiorespiratory fitness testing is an alternative method of measuring cardiorespiratory fitness. It is recommended when exercising at moderate intensity, 7 and may be more tolerated by people with stroke. 6 Despite barriers to the uptake of cardiorespiratory fitness testing (ie, stroke-related impairments, testing being costly and time consuming), the safety and feasibility of fitness testing in chronic stroke has been well documented. ...
... 38 This work may improve a clinician's knowledge and confidence to initiate safe, tailored cardiorespiratory fitness training early after stroke in people with mild-to-moderately severe stroke, 38 as recommended in multiple national guidelines. 1,2,7 Only one minor adverse event was recorded (exacerbation of a pre-existing knee condition), but this did not limit function or further participation in rehabilitation. There were no cardiovascular adverse events or serious adverse events associated with cardiorespiratory fitness testing. ...
Article
Introduction: Cardiorespiratory fitness testing is recommended as part of a pre-exercise evaluation to aid the programming of safe, tailored cardiorespiratory fitness training after stroke. But there is limited evidence for its safety and feasibility in people with stroke with varying impairment levels in the early subacute phase of stroke recovery. Objective: To assess the safety and feasibility of cardiorespiratory fitness testing in the early subacute phase after stroke. Design: A sub-study of a larger single service, multi-site, prospective cohort feasibility study (Cardiac Rehabilitation in Stroke Survivors to Improve Survivorship [CRiSSIS]). Setting: Private subacute inpatient rehabilitation facilities. Participants: Consecutive admissions of people with ischaemic stroke admitted to subacute rehabilitation facilities. Intervention: Not applicable. Main outcome(s): Safety was determined by the occurrence of adverse or serious adverse events. Feasibility was determined by assessing the: 1) number of participants recruited, and 2) number of participants able to complete the fitness test. Results: Between April 2018 and December 2019, 165 people with stroke were screened to participate, 109 were eligible and 65 were recruited. Of the 62 that completed testing, 41 were able to complete a submaximal fitness test at a median of 12 days post-stroke. One minor adverse event was recorded. Of the 21 participants unable to complete the fitness test; four declined to complete the test, nine were unable to commence the test, and eight were unable to complete the first stage of the protocol due to stroke-related impairments. Participants with mild stroke, greater motor and cognitive function and fewer depressive symptoms were more likely to be able to complete the cardiorespiratory fitness test. Conclusions: Cardiorespiratory fitness testing was safe for most people with mild-to-moderately severe ischaemic stroke and transient ischaemic attack in the early subacute phase, but only two-thirds of the participants could complete the test. This article is protected by copyright. All rights reserved.
... 12,13 Exercise training is a recommended core component of stroke rehabilitation. 14,15 The majority of literature in individuals with stroke focuses on aerobic exercise training, but resistance and neuromuscular training are also critical aspects of a comprehensive program. Exercise training can facilitate functional recovery (e.g., mobility and cognitive function), 16,17 improved cardiorespiratory fitness, 16 cardiovascular risk factors, 18 muscular strength, 19 and markers of neurorecovery. ...
... 37 This response is thought to be beneficial for lowering systemic inflammation and may reduce the intensity of symptoms associated with viral infection (Figure 1 Part D). 36,37 Recent data suggest that participating in regular physical activity was strongly associated with a reduced risk for severe COVID-19 outcomes among infected adults without stroke. 38 Taken together, the initiation of relatively short bouts of exercise performed at low to moderate intensity is likely a safe and beneficial therapeutic strategy for improving multiple systems in individuals post-stroke who are deemed medically stable (e.g., typically in the early sub-acute phase) 14 and who are ≥14 days symptom-free with suspected or confirmed post-COVID-19 infection (refer to Figure 2). Additionally, moderate-intensity exercise may provide protective effects against infection by strengthening the immune system for individuals who are not infected. ...
... Return to physical activity and exercise is vital for stroke recovery, but appropriate and safe participation requires adequate pre-participation screening and eligibility assessment for exercise stroke rehabilitation, 14,15,81 especially in the context of post-COVID-19 rehabilitation. Only qualified healthcare professionals should assess safety and suitability for graded exercise stress testing with or without electrocardiography (ECG) and metabolic gas exchange, and training for individuals post-stroke, 14 including those who may have a suspected or confirmed COVID-19 infection. ...
Article
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Background. The COVID-19 pandemic attributable to the severe acute respiratory syndrome virus (SARS-CoV-2) has had a significant and continuing impact across all areas of healthcare including stroke. Individuals post-stroke are at high risk for infection, disease severity, and mortality after COVID-19 infection. Exercise stroke rehabilitation programs remain critical for individuals recovering from stroke to mitigate risk factors and morbidity associated with the potential long-term consequences of COVID-19. There is currently no exercise rehabilitation guidance for people post-stroke with a history of COVID-19 infection. Purpose. To (1) review the multi-system pathophysiology of COVID-19 related to stroke and exercise; (2) discuss the multi-system benefits of exercise for individuals post-stroke with suspected or confirmed COVID-19 infection; and (3) provide clinical considerations related to COVID-19 for exercise during stroke rehabilitation. This article is intended for healthcare professionals involved in the implementation of exercise rehabilitation for individuals post-stroke who have suspected or confirmed COVID-19 infection and non-infected individuals who want to receive safe exercise rehabilitation. Results. Our clinical considerations integrate pre-COVID-19 stroke (n = 2) and COVID-19 exercise guidelines for non-stroke populations (athletic [n = 6], pulmonary [n = 1], cardiac [n = 2]), COVID-19 pathophysiology literature, considerations of stroke rehabilitation practices, and exercise physiology principles. A clinical decision-making tool for COVID-19 screening and eligibility for stroke exercise rehabilitation is provided, along with key subjective and physiological measures to guide exercise prescription. Conclusion. We propose that this framework promotes safe exercise programming within stroke rehabilitation for COVID-19 and future infectious disease outbreaks.
... Guidance on exercise interventions for PwS stipulate specific parameters for aerobic conditioning and resistance training to optimise physiological response [16]. PAE machines offer varied speed settings but the duration and intensity of exercise is not based upon the exercise prescription detailed in published guidelines [16]. ...
... Guidance on exercise interventions for PwS stipulate specific parameters for aerobic conditioning and resistance training to optimise physiological response [16]. PAE machines offer varied speed settings but the duration and intensity of exercise is not based upon the exercise prescription detailed in published guidelines [16]. Furthermore, the existing software does not measure or quantify the physical effort generated by the user. ...
... The range of priorities expressed illustrated the value of consultation with diverse experts in the preliminary phase of the co-design project. Published exercise guidelines for PwS have focussed on improvements in aerobic capacity and muscular performance [16]; whereas physical rehabilitation for PwS has prioritised quality of movement and functional recovery [28]. Assisted exercise enhances motor recovery and improves aerobic capacity for PwS [29] and therefore may bridge the historical gap which has existed between exercise and rehabilitation perspectives. ...
Article
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Plain English Summary Seated power assisted exercise machines assist different combinations of movement and can help people with stroke to take part in exercise programmes. Nine seated machines are manufactured in the UK. It was identified that the machines could be improved through development of technology to detect and display the user’s physical effort during exercise. The research team successfully applied for funding to design and develop a new programme to display and measure user effort whilst exercising on the equipment. At the outset of the project the research team needed to make decisions about the capabilities of the new technology and select three machines from the range of nine to be prototyped. We used a method called nominal group technique during which end users with stroke, rehabilitation and exercise professionals were invited to structured meetings to share their ideas. At the end of the meetings the groups voted on their preferred machines. The ideas expressed during the meetings were listed and guided the ongoing development of the technology. The importance of a user-friendly interface was emphasised. The three machines which were allocated the most votes across the user groups were selected to be redesigned and developed with the new technology. The involvement of users at the outset of the design project ensured that they directly influenced the selection of machines and features of the new technology. Nominal group technique was an effective way of ensuring that all attendees had the opportunity to share their ideas and perspectives.
... ambulatory people after a stroke. Given that the recovery of mobility after stroke remains the main goal for stroke survivors and a challenge for stroke rehabilitation clinicians (Balasubramanian, Clark & Fox 2014), adding aerobic exercises to conventional care could promote functional recovery of mobility in stroke survivors (MacKay-Lyons et al. 2020). ...
... Luo et al. (2019) reported that a high-intensity exercise programme (70% -85% HRR/VO2 peak, 3-5 times lasting 30-40 minutes per week for 8-12 weeks) was beneficial for walking competency in patients with subacute and chronic stroke. The body of literature reported that the benefits of AT result from the interaction between the frequency of sessions, session duration and intervention length (MacKay-Lyons et al. 2020). Our review showed that the dosage of these parameters (frequency, intensity and time) is essential in AT interventions to promote walking recovery in the chronic stroke phase. ...
Article
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Background: Although aerobic training (AT) and resistance training (RT) are recommended after stroke, the optimal dosage of these interventions and their effectiveness on balance, walking capacity, and quality of life (QoL) remain conflicting. Objective: Our study aimed to quantify the effects of different modes, dosages and settings of exercise therapy on balance, walking capacity, and QoL in stroke survivors. Methods: PubMed, CINHAL, and Hinari databases were searched for randomised controlled trials (RCTs) evaluating the effects of AT and RT on balance, walking, and QoL in stroke survivors. The treatment effect was computed by the standard mean differences (SMDs). Results: Twenty-eight trials (n = 1571 participants) were included. Aerobic training and RT interventions were ineffective on balance. Aerobic training interventions were the most effective in improving walking capacity (SMD = 0.37 [0.02, 0.71], p = 0.04). For walking, capacity, a higher dosage (duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve) of AT interventions demonstrated a significantly greater effect (SMD = 0.58 [0.12, 1.04], p = 0.01). Combined AT and RT improved QoL (SMD = 0.56 [0.12, 0.98], p = 0.01). Hospital located rehabilitation setting was effective for improving walking capacity (SMD = 0.57 [0.06, 1.09], p = 0.03) compared with home and/or community and laboratory settings. Conclusions: Our findings showed that neither AT nor RT have a significant effect on balance. However, AT executed in hospital-located settings with a higher dose is a more effective strategy to facilitate walking capacity in chronic stroke. In contrast, combined AT and RT is beneficial for improving QoL. Clinical implications: A high dosage of aerobic exercise, duration ≥ 120 min/week; intensity ≥ 60% heart rate reserve is beneficial for improving walking capacity.
... When severe diffuse atherosclerosis occurs in cerebral vessels, coronary arteries, or peripheral arteries, surgical or medical treatment usually shows poor effect and the patients would have a poor prognosis. Exercise rehabilitation therapy can significantly improve the symptoms and prognosis of patients with ischemic stroke, ischemic heart disease, and peripheral artery disease (Treat-Jacobson et al., 2019;MacKay-Lyons et al., 2020;Pelliccia et al., 2021), and has already been used as a treating method along with medication and surgical operation. Skeletal muscle is the main organ involved in exercise, in the meantime, it is also the largest glycogen reserve organ and an important endocrine organ. ...
... Therefore, the application prospect of gene therapy to promote peripheral angiogenesis is unclear yet (Simon et al., 2022). Compared with these above strategies, exercise rehabilitation has been incorporated into many authoritative guidelines as an improvement method for many ischemic diseases (Treat-Jacobson et al., 2019;MacKay-Lyons et al., 2020;Pelliccia et al., 2021). Exercise-mediated improvement of ischemic symptoms is closely related to angiogenesis promotion. ...
Article
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Ischemic diseases are a major cause of mortality or disability in the clinic. Surgical or medical treatment often has poor effect on patients with tissue and organ ischemia caused by diffuse stenoses. Promoting angiogenesis is undoubtedly an effective method to improve perfusion in ischemic tissues and organs. Although many animal or clinical studies tried to use stem cell transplantation, gene therapy, or cytokines to promote angiogenesis, these methods could not be widely applied in the clinic due to their inconsistent experimental results. However, exercise rehabilitation has been written into many authoritative guidelines in the treatment of ischemic diseases. The function of exercise in promoting angiogenesis relies on the regulation of blood glucose and lipids, as well as cytokines that secreted by skeletal muscle, which are termed as myokines, during exercise. Myokines, such as interleukin-6 (IL-6), chemokine ligand (CXCL) family proteins, irisin, follistatin-like protein 1 (FSTL1), and insulin-like growth factor-1 (IGF-1), have been found to be closely related to the expression and function of angiogenesis-related factors and angiogenesis in both animal and clinical experiments, suggesting that myokines may become a new molecular target to promote angiogenesis and treat ischemic diseases. The aim of this review is to show current research progress regarding the mechanism how exercise and exercise-induced myokines promote angiogenesis. In addition, the limitation and prospect of researches on the roles of exercise-induced myokines in angiogenesis are also discussed. We hope this review could provide theoretical basis for the future mechanism studies and the development of new strategies for treating ischemic diseases.
... ere are two parts to sports fatigue detection: sports data acquisition and data-driven recognition algorithm [5]. ...
... where N is the sum of pixels in the rectangular window, that is, N � L × W × W. e probability density of each pixel can be obtained, and the entropy of each pixel can be calculated by (5) to obtain the SE image. ...
Article
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Excessive exercise can strengthen the body and make people happy, but it can also cause physical injury. To address this issue, this paper proposes the TFD-SE (Three-Frame Difference Spatiotemporal Entropy) algorithm and the LB (Label Propagation) algorithm, which are both based on SE (spatiotemporal entropy) and label technology. The TFD-SE algorithm calculates the difference image using the three-frame difference method, then calculates the SE of pixels in the difference image, and performs morphological filtering and threshold segmentation, allowing it to detect moving objects effectively. The significance value of unlabeled nodes in the image is calculated using the LB algorithm. In both qualitative and quantitative comparisons, the experimental results show that both algorithms outperform other classical algorithms in terms of detection performance.
... In 3 studies, the NIHSS was used as a measure of stroke severity, 53,58,61 predominantly recruiting people with mild stroke (NIHSS=4. [2][3][4][5]. In 1 study, the Scandinavian Stroke Scale 59 was used, with predominantly mild stroke participants recruited (mean score, 54). ...
... 2,12,18 Given the importance of lifelong cardiorespiratory fitness, future research needs to target the factors that influence long-term engagement in cardiorespiratory fitness training and physical activity and identify the long-term effects in people with stroke. Therefore, further investigations are required to assess (1) what model of care best supports long-term cardiorespiratory fitness maintenance (eg, group vs individual training, center vs home-based training), (2) the nature of the interventions (ie, cardiorespiratory fitness training alone or in combination with mixed interventions [ie, resistance or balance or stepping training] and/or education and/or ongoing monitoring), (3) what dose parameters of a cardiorespiratory fitness interventions optimize long-term maintenance of cardiorespiratory fitness (ie, intervention type, frequency, intensity, and length), and (4) long-term monitoring of risk factors, such as physical inactivity and low cardiorespiratory fitness, to determine the effect of the intervention on behavior change in people with stroke. ...
Article
Objective: To determine if improvements in cardiorespiratory fitness are maintained in the short-, medium- and long-term after a cardiorespiratory fitness intervention in people with stroke. Data sources: MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, (CENTRAL) Cochrane, Web of Science, Sports Discus, and Physiotherapy Evidence Database were searched from inception. Study selection: Randomized controlled trials and cohort studies including (1) people with stroke; (2) cardiorespiratory fitness interventions; (3) a direct measure of cardiorespiratory fitness; and (4) short- (0 to <3 months), medium- (3-6 months), or long-term (>6 months) follow-up data. Data extraction: Two reviewers independently screened full texts and extracted data, including study methods, participant demographic information, stroke type and severity, outcome measures, intervention information, follow-up time points, and results, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A lower limit of -1.0 mL•kg-1•min-1 was used to determine maintenance (ie, no change) of cardiorespiratory fitness. Data synthesis: Fourteen studies (N=324 participants) were included. Participants completed cardiorespiratory fitness training 2-5 days per week over 4-13 weeks at moderate to high intensity (40%-70% heart rate reserve [HRR]; n=4 studies), high intensity (60% to <90% HRR; n=7 studies), and intervals of high intensity (85%-95% peak heart rate or maximal heart rate; n=3 studies). Most people with stroke did maintain cardiorespiratory fitness in the short- (-0.19 mL•kg-1•min-1 [95% CI, -1.66 to 1.28]), medium- (-0.61 mL•kg-1•min-1 [95% CI, -3.95 to 2.74]), and long-term (0.00 mL•kg-1•min-1 [95% CI, -2.23 to 2.23]) after completion of cardiorespiratory fitness interventions. Conclusions: People with stroke maintain cardiorespiratory fitness after a cardiorespiratory fitness intervention in the short-, medium-, and longer-term. However, little is known about the impact of participant and intervention characteristics on the long-term maintenance of cardiorespiratory fitness.
... In 3 studies, the NIHSS was used as a measure of stroke severity, 53,58,61 predominantly recruiting people with mild stroke (NIHSS=4. [2][3][4][5]. In 1 study, the Scandinavian Stroke Scale 59 was used, with predominantly mild stroke participants recruited (mean score, 54). ...
... 2,12,18 Given the importance of lifelong cardiorespiratory fitness, future research needs to target the factors that influence long-term engagement in cardiorespiratory fitness training and physical activity and identify the long-term effects in people with stroke. Therefore, further investigations are required to assess (1) what model of care best supports long-term cardiorespiratory fitness maintenance (eg, group vs individual training, center vs home-based training), (2) the nature of the interventions (ie, cardiorespiratory fitness training alone or in combination with mixed interventions [ie, resistance or balance or stepping training] and/or education and/or ongoing monitoring), (3) what dose parameters of a cardiorespiratory fitness interventions optimize long-term maintenance of cardiorespiratory fitness (ie, intervention type, frequency, intensity, and length), and (4) long-term monitoring of risk factors, such as physical inactivity and low cardiorespiratory fitness, to determine the effect of the intervention on behavior change in people with stroke. ...
Article
Objective(s) To determine if improvements in cardiorespiratory fitness are maintained in the short-, medium- and long-term following a cardiorespiratory fitness intervention in people with stroke. Data Sources Medline, CINAHL, Embase, (CENTRAL) Cochrane, Web of Science, Sports Discus and Physiotherapy Evidence Database (PEDRO) were searched from inception. Study Selection Randomised controlled trials and cohort studies including 1) people with stroke, 2) a cardiorespiratory fitness intervention, 3) a direct measure of cardiorespiratory fitness, and 4) short- (0- < 3 months), medium- (3-6 months), or long-term (>6 months) follow-up data. Data Extraction Two reviewers independently screened full texts and extracted data. Data including study methods, outcome measures and results was extracted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A lower limit of -1.0 ml.kg-1.min-1 was used to determine maintenance (i.e., no change) in cardiorespiratory fitness. Data Synthesis Fourteen studies (n=324 participants) were included. Participants completed cardiorespiratory fitness training 2-5 days per week over 4-13 weeks at moderate-to-high intensity (40-70% heart rate reserve [HRR]; n=4 studies), high intensity (60- < 90% HRR; n=7 studies) and high intensity intervals (85-95%HRpeak or HRmax; n=3 studies). Most people with stroke do maintain cardiorespiratory fitness in the short- (-0.19 ml.kg-1.min-1 [95%CIs -1.66, 1.28]), medium- (-0.61 ml.kg-1.min-1 [95%CIs -3.95, 2.74]), and long-term (-0.00 ml.kg-1.min-1 [95%CIs -2.23, 2.23]) following completion of cardiorespiratory fitness interventions. Conclusions People with stroke maintain cardiorespiratory fitness following a cardiorespiratory fitness intervention in the short-, medium-, and long-term. However, little is known about the impact of participant and intervention characteristics on the long-term maintenance of cardiorespiratory fitness. Author(s) Disclosures The authors have no disclosures.
... The safety and feasibility of the 6MWD have been reported for patients with acute stroke 8) , and this test offers a practical and easy assessment index that does not require special equipment. The 6MWD offers a good reflection of aerobic capacity 9,10) and is recommended for the clinical assessment of aerobic capacity and walking endurance in adults under rehabilitation for acute neurological deficit 11,12) . Cross-sectional validation has also reported that the 6MWD is the best single predictive discriminant of walking activity in stroke patients 13,14) . ...
Article
[Purpose] This study aimed to compare the predictive accuracy of walking ability at discharge among subacute stroke inpatients at 6 months post-discharge in terms of community ambulation level and establish optimal cut-off values. [Participants and Methods] This prospective observational study included 78 patients who completed follow-up assessments. Patients were classified into three groups based on the Modified Functional Walking Category (household/most limited community walkers, least limited community walkers, and unlimited community walkers) obtained by telephone survey at 6 months post-discharge. Predictive accuracy and cut-off values for discriminating among groups were calculated from 6-minute walking distance and comfortable walking speed measured at the time of discharge using receiver operating characteristic curves. [Results] Between household/most limited and least limited community walkers, 6-minute walking distance and comfortable walking speed offered similar predictive accuracy (area under the curve, 0.6–0.7), with cut-off values of 195 m and 0.56 m/s, respectively. Between least limited and unlimited community walkers, the areas under the curve were 0.896 for 6-minute walking distance and 0.844 for comfortable walking speed, with cut-off values of 299 m and 0.94 m/s, respectively. [Conclusion] Walking endurance and walking speed among inpatients with subacute stroke provided superior predictive accuracy for unlimited community walkers at 6 months post-discharge.
... This randomised controlled feasibility study will be the first of its kind to investigate online neuropilates training in stroke survivors. The evidence for exercise therapy in stroke is plentiful with aerobic exercise [49,50] and "mixed training" (circuit training, resistance exercises and task orientated training) [9] being recommended in most clinical guidelines to improve fitness, balance and walking. Neuropilates has achieved some preliminary outcomes of balance and gait improvements in a small-scale systematic review [18] but further investigation is warranted before it could be recommended in this population as part of a clinical guideline. ...
Article
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Introduction: Stroke survivors often demonstrate low physical activity levels and experience barriers to physical exercise including embarrassment, low self-efficacy and a shortage of tailored community exercise programmes. Access to physical activity programmes for stroke survivors could be improved by providing tailored, online programmes, although little is known about the safety and feasibility of online exercise classes for stroke survivors. One such programme of exercise which has received little attention in the literature is neuropilates. Neuropilates is the practice of a modified pilates programme in those with neurological conditions and is theorised to have beneficial effects on strength, balance and proprioception in stroke survivors. No previous study has been conducted to investigate online, remotely supervised neuropilates exercise classes in the stroke survivors. Method and analysis: This single assessor blinded randomised controlled feasibility study will compare a 6-week online, remotely instructed neuropilates programme to a 6-week online, remotely instructed generalised exercise programme and a 6-week unsupervised generalised home exercise programme in chronic stroke patients. Twenty adults, at least 6 months post stroke, and finished their formal rehabilitation will be recruited to the study. Primary feasibility outcome measures will include patient tolerance of the programme, adherence rates, adverse events, recruitment and retention. Secondary clinical outcomes will include; balance, gait, tone and quality of life. Assessments will be completed at baseline, on programme completion and 3 months post completion by a Physiotherapist blinded to the group allocation. Ethics and dissemination: This study has received ethical approval from the Sligo University Hospital Ethics committee and ATU ethics board. Results will be published in peer-reviewed journals and presented at national and international conferences.The trial has been registered on clinicaltrials.gov (Identifier: NCT04491279).
... Despite these benefits, and clinical guidelines encouraging PA promotion during and after rehabilitation [2,5,6], PWS remain inactive, spending > 80% of waking hours sedentary even when they have physical capacity for activity [7]. Qualitative research with PWS suggests complex barriers to PA [8,9], and even after participation in post-rehabilitation exercise programmes, regular PA is often not maintained [10,11]. ...
Article
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Background Evidence for benefits of physical activity after stroke is unequivocal. However, many people with stroke are inactive, spending > 80% of waking hours sedentary even when they have physical capacity for activity, indicating barriers to physical activity participation that are not physical. WeWalk is a 12-week person-centred dyadic behaviour change intervention in which a person with stroke (PWS) and a walking buddy form a dyad to work together to support the PWS to increase their physical activity by walking outdoors. This pilot study examined the feasibility of recruiting dyads, explored their perceptions of acceptability and their experiences using WeWalk, to identify required refinements before progression to a clinical trial. Methods Design: A single-arm observational pilot study with qualitative evaluation. Intervention: WeWalk involved facilitated face-to-face and telephone sessions with a researcher who was also a behaviour change practitioner, supported by intervention handbooks and diaries, in which dyads agreed walking goals and plans, monitored progress, and developed strategies for maintaining walking. Evaluation: Descriptive data on recruitment and retention were collected. Interview data were collected through semi-structured interviews and analysed using thematic analysis, guided by a theoretical framework of acceptability. Results We recruited 21 dyads comprising community dwelling PWS and their walking buddies. Ten dyads fully completed WeWalk before government-imposed COVID-19 lockdown. Despite lockdown, 18 dyads completed exit interviews. We identified three themes: acceptability evolves with experience, mutuality, and person-centredness with personally relevant tailoring. As dyads recognised how WeWalk components supported walking, perceptions of acceptability grew. Effort receded as goals and enjoyment of walking together were realised. The dyadic structure provided accountability, and participants’ confidence developed as they experienced physical and psychological benefits of walking. WeWalk worked best when dyads exhibited relational connectivity and mutuality in setting and achieving goals. Tailoring intervention components to individual circumstances and values supported dyads in participation and achieving meaningful goals. Conclusion Recruiting dyads was feasible and most engaged with WeWalk. Participants viewed the dyadic structure and intervention components as acceptable for promoting outdoor walking and valued the personally tailored nature of WeWalk. Developing buddy support skills and community delivery pathways are required refinements. ISCTRN number: 34488928.
... 1,3 Therefore, clinical guidelines have recommended that individuals post-stroke perform aerobic exercise to increase cardiorespiratory fitness levels. [4][5][6] Furthermore, the cardiorespiratory fitness has been considered a vital clinical sign that must be frequently evaluated in clinical practice for the health and functionality care of individual. 7 Thus, the assessment of cardiorespiratory fitness is important for the rehabilitation process of individuals post-stroke. ...
Article
Objective To develop an equation with clinical applicability and adequate validity to predict the maximum oxygen consumption (VO2max) of individuals post-stroke. Design Cross-sectional study. Setting University laboratory. Participants Individuals post-stroke in the chronic phase (at least six months post-stroke). Step-1 (equation development): n=50, aged 55±12 years; Step-2 (validity investigation): n=20, aged 58±8 years. Interventions Not applicable. Main Outcome Measure(s) Step-1 (equation development): multiple linear regression analysis was performed. Dependent variable: VO2max (ml.kg–1.min–1) in the cardiopulmonary exercise test (CPET). Independent variables: age (years), sex (1-female, 2-male), body mass index (BMI) (kg/m²), and distance (meters) in the Six-Minute Walk Test (6MWT) (6MWT-Equation) or in the Incremental Shuttle Walk Test (ISWT) (ISWT-Equation). Step-2 (validity investigation): agreement between the VO2max measured and predicted was evaluated with the intraclass correlation coefficient (ICC) with 95% confidence interval (95%CI) and the Bland-Altman method (α=5%). Results In step-1 (equation development), the four independent variables for each equation were retained (6MWT-Equation: R²=0.68, p<0.001; ISWT-Equation: R²=0.58, p<0.001). In step-2 (validity investigation), the 6MWT-Equation showed an ICC of 0.73 (95%CI=0.30, 0.89; p=0.004) and a mean bias of 0.003 ml.kg–1.min–1; and the ISWT-Equation showed an imprecise ICC of 0.55 (95%CI=-0.12, 0.82; p=0.045) and a mean bias of 0.971 ml.kg–1.min–1. 6MWT-Equation (VO2max=22.239+0.02*distance in the 6MWT+4.039*sex-0.157*age-0.265*BMI) showed adequate validity. Conclusions An equation with clinical applicability and adequate validity in the investigated sample was developed to predict the VO2max of individuals post-stroke in the chronic phase (6MWT-Equation). Future studies with larger sample should investigate its external validity.
... Aerobics can be performed in a variety of environments, and its use of venues has a certain collective nature, so it provides a variety of opportunities for corporate advertising. Aerobics is favored by many companies [4,5]. However, due to the complexity and professionalism of the technical movements of aerobics, ordinary people often face different situations in the learning process. ...
Article
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At present, aerobics is becoming a popular fashion with the continuous development of cultural needs. Because aerobics has the characteristics of many movements, rapid changes, strong complexity, and difficult performance of difficult movements, the current aerobics teaching still presents shortcomings such as low teaching level, limited teachers’ resources, and energy. Therefore, it is difficult to effectively meet the actual learning needs of students. Based on this point, artificial intelligence can be used to simulate and guide the technical movements of aerobics to effectively teach students. In this paper, an artificial intelligence aerobics image simulation system is researched and developed and the GrabCut image segmentation algorithm is mainly used. After analyzing some shortcomings of the algorithm, the GrabCut algorithm cascade and graph-based are selected to complete the optimization, so as to lay a good system foundation and then build the aerobics artificial intelligence image simulation system according to the algorithm foundation. Finally, it analyzes and researches the actual problems of aerobics teaching activities in colleges and universities and focuses on the problems, achievements, and personal satisfaction of students who use the system in actual learning, which proves that the system can effectively assist aerobics teaching activities. By studying the image segmentation algorithm and artificial intelligence technology, this paper applies it to the field of aerobics action image simulation, so as to promote its technological development.
... Focus will be on walking and functional weight-bearing activities, to work toward meeting national stroke guidelines. 3,4 The inpatient unit will be provided with an activity tracking watch that clinicians will use to monitor heart rate (Garmin Forerunner 235, Garmin Ltd., USA) and a step counter to monitor the number of steps (Fitbit Inspire, Alphabet Inc., USA, placed on the ankle) 11 during physical therapy sessions. All eligible participants with stroke admitted to the unit will receive the Walk 'n Watch protocol as it will be considered standard care, even if they have not consented to the study. ...
Article
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Rationale: Clinical practice guidelines support structured, progressive protocols for improving walking after stroke. Yet, practice is slow to change, evidenced by the little amount of walking activity in stroke rehabilitation units. Our recent study (n=75) found that a structured, progressive protocol integrated with typical daily physical therapy improved walking and quality of life measures over usual care. Research therapists progressed the intensity of exercise by using heart rate and step counters worn by the participants with stroke during therapy. To have the greatest impact, our next step is to undertake an implementation trial to change practice across stroke units where we enable the entire unit to use the protocol as part of standard of care. Aims: What is the effect of introducing structured, progressive exercise (termed the Walk ‘n Watch protocol) to standard of care on the primary outcome of walking in adult participants with stroke over the hospital inpatient rehabilitation period? Secondary outcomes will be evaluated and include quality of life. Methods and sample size estimates: This national, multisite clinical trial will randomize 12 sites using a stepped-wedge design where each site will be randomized to deliver Usual Care initially for 4, 8, 12 or 16-months (three sites for each duration). Then, each site will switch to the Walk ‘n Watch phase for the remaining duration of a total 20-month enrolment period. Each participant will be exposed to only one of Usual Care or Walk ‘n Watch. The trial will enrol a total of 195 participants with stroke to achieve a power of 80% with a Type I error rate of 5%, allowing for 20% dropout. Participants will be medically stable adults post-stroke and able to take 5 steps with a maximum physical assistance from one therapist. The Walk ‘n Watch protocol focuses on completing a minimum of 30-minutes of weight-bearing, walking-related activities (at the physical therapists’ discretion) that progressively increases in intensity informed by activity trackers measuring heart rate and step number. Study outcome(s): The primary outcome will be the change in walking endurance, measured by the Six-Minute Walk Test, from Baseline (T1) to 4-weeks (T2). This change will be compared across Usual Care and Walk ‘n Watch phases using a linear mixed-effects model. Additional physical, cognitive, and quality of life outcomes will be measured at T1, T2, and 12-months post-stroke (T3) by a blinded assessor. Discussion: The implementation stepped-wedge cluster-randomized trial enables the protocol to be tested under real-world conditions, involving all clinicians on the unit. It will result in all sites and all clinicians on the unit to gain expertise in protocol delivery. Hence, a deliberate outcome of the trial is facilitating changes in best practice to improve outcomes for participants with stroke in the trial, and for the many participants with stroke admitted after the trial ends.
... The Recommendations below are based on the American and Canadian guidelines 33,35 . ...
Article
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The Guidelines for Stroke Rehabilitation are the result of a joint effort by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology aiming to guide professionals involved in the rehabilitation process to reduce functional disability and increase individual autonomy. Members of the group participated in web discussion forums with predefined themes, followed by videoconference meetings in which issues were discussed, leading to a consensus. These guidelines, divided into two parts, focus on the implications of recent clinical trials, systematic reviews, and meta-analyses in stroke rehabilitation literature. The main objective was to guide physicians, physiotherapists, speech therapists, occupational therapists, nurses, nutritionists, and other professionals involved in post-stroke care. Recommendations and levels of evidence were adapted according to the currently available literature. Part I discusses topics on rehabilitation in the acute phase, as well as prevention and management of frequent conditions and comorbidities after stroke. Keywords: Stroke; Guideline; Neurological Rehabilitation; Practice Guidelines as Topic
... As mentioned previously, there is strong evidence for the use of cardiovascular exercise, and it is a recommended component of stroke rehabilitation [1]. As it currently stands, the conventional use of MICT could be an insufficient cardiovascular stimulus to elicit improvement in neuroplasticity and cardiovascular health [88]. ...
Article
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Rationale Cardiovascular exercise is an effective method to improve cardiovascular health outcomes, but also promote neuroplasticity during stroke recovery. Moderate-intensity continuous cardiovascular training (MICT) is an integral part of stroke rehabilitation, yet it may remain a challenge to exercise at sufficiently high intensities to produce beneficial adaptations to neuroplasticity. High-intensity interval training (HIIT) could provide a viable alternative to achieve higher intensities of exercise by using shorter bouts of intense exercise interspersed with periods of recovery. Methods and design This is a two-arm, parallel-group multi-site RCT conducted at the Jewish Rehabilitation Hospital (Laval, Québec, Canada) and McMaster University (Hamilton, Ontario, Canada). Eighty participants with chronic stroke will be recruited at both sites and will be randomly allocated into a HIIT or MICT individualized exercise program on a recumbent stepper, 3 days per week for 12 weeks. Outcomes will be assessed at baseline, at 12 weeks post-intervention, and at an 8-week follow-up. Outcomes The primary outcome is corticospinal excitability, a neuroplasticity marker in brain motor networks, assessed with transcranial magnetic stimulation (TMS). We will also examine additional markers of neuroplasticity, measures of cardiovascular health, motor function, and psychosocial responses to training. Discussion This trial will contribute novel insights into the effectiveness of HIIT to promote neuroplasticity in individuals with chronic stroke. Trial registration ClinicalTrials.gov NCT03614585 . Registered on 3 August 2018
... This program also may include balance training, gait training, muscle strengthening, functional use of the upper extremity, motor control which is task oriented. (16) Due to the various benefits of exercises for stroke rehabilitation, it should be a common practice among patients post stroke. There is little is known about adherence to a HEP prescribed by a physical therapist in older adults following discharge or about the factors that affect post discharge adherence. ...
Article
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Background: Stroke, also known as cerebrovascular accident is caused when the brain does not receive enough blood supply, thus preventing brain from receiving oxygen and nutrients. Its divided into two major categories: ischemic and hemorrhagic. A stroke is a medical emergency, and prompt treatment is crucial. Objective: To determine the level of exercise compliance following Physical Therapy treatment in patients with stroke. Methodology: This cross-sectional study was conducted in different hospitals of Lahore on 139 participants in Lahore, ages between 45 to 70, both genders, patients with both ischemic and/or hemorrhagic stroke and those following a home based plan were included for the study. Any participants unwilling for follow-ups, with cognitive impairments, diabetes or ischemic heart disease and unable to communicate were excluded. For the collection of the data, a researcher designed questionnaire was used. An informed consent was taken from the study participants. SPSS 25 was used for data analysis. Results: 31.7% of the participants agreed that exercise was beneficial to health and 36.7% remained neutral. 23.0% strongly agreed and 25.9% agreed their preference were scheduled exercise programs. 35.3% agreed to feel better when they were active and 30.9% disagreed to this. Sense of accomplishment, keep mind active and good for heart were significant motivators to exercise adherence. Lack of strength, shortness of breath and bad weather were significant barriers. Conclusion: There was little to moderate level of compliance with exercise in patients with stroke following physiotherapy intervention.
... For the video and realtime camera of aerobics, this paper uses the N-best algorithm to estimate the human pose parameters in a single frame; the iterative self-organizing data analysis technique (ISODATA) algorithm is used to determine the keyframes dynamically. In the aerobics video keyframe extraction experiments, the ST-FMP model improves the recognition accuracy of nondeterministic body parts of the flexible hybrid articulated human model (FMP) by about 15 percentage points [10]. ...
Article
Full-text available
With the in-depth integration of information technology and subject teaching, it is also an inevitable trend to apply modern information technology to aerobics teaching. In this paper, the N-best algorithm is used in the video and real-time camera in aerobics, so that the human posture parameters in a single-frame image can be estimated. By using the relative position and motion direction of each part of the human body to describe the characteristics of aerobics, the Laplace scoring method is used to reduce the dimension of the data, and the discriminant human motion feature vector with a strong local topological structure is obtained. Finally, the iterative self-organizing data analysis technology (ISODATA algorithm) is used to dynamically determine the keyframe. In the aerobics video keyframe extraction experiments, the ST-FMP model improves the recognition accuracy of nondeterministic body parts of the flexible hybrid articulated human model (FMP) by about 15 percentage points and achieves 81% keyframe extraction accuracy, which is better than the keyframe algorithms of KFE and motion block. The proposed algorithm is sensitive to human motion features and human pose and is suitable for motion video annotation review.
... Although participants exercised at a common time, activities prescribed by the supervising kinesiologists were individualized based on initial assessment performance and participant goals. Generally, all programs included cardiorespiratory exercise, strength training, and practice of functional movements to support activities of daily living, with program design informed by exercise prescription principles described by the Canadian Society for Exercise Physiology (2021), the American College of Sports Medicine (Liguori et al., 2020), and any available evidence-based guidelines for an individual's specific neurological condition (Kalb et al., 2020;Kim et al., 2019;MacKay-Lyons et al., 2020;Martin Ginis et al., 2018;Palmer-McLean & Harbst, 2009). The programs were modified and progressed by the kinesiologists over the course of the program. ...
Article
A mixed-methods approach was used to study an individually-tailored community exercise program for people with a range of chronic neurological conditions (e.g., stroke, spinal cord injury, brain injury, multiple sclerosis, Parkinson’s disease) and abilities. The program was delivered to older adults (mean age: 62 ± 9 years) with chronic neurological conditions across a 12-week and an 8-week term. Participants attended 88% of sessions and completed 89% of prescribed exercises in those sessions. There were no adverse events. Clinically important improvements were achieved by all evaluated participants ( n = 8) in at least one testing domain (grip strength, lower-extremity strength, aerobic endurance, and balance). Interviews with participants identified key program elements as support through supervision, social connection, individualized programming, and experiential learning. Findings provide insight into elements that enable a community exercise program to meet the needs of a complex and varied group. Further study will support positive long-term outcomes for people aging with neurological conditions.
... 6 Consequently, recommendations for exercise prescription have been developed to guide health professionals working in stroke rehabilitation. 6,13 Recommendations state stroke patients should aim to engage in aerobic exercise on 3-5 d/wk and muscular strength and endurance training on 2-3 d/wk. In this context, circuit resistance training (CRT) has emerged as an effective and timeefficient strategy to improve strength of the lower and upper limbs, cardiorespiratory fitness, and body composition. ...
Article
Purpose: The main aim of this study was to investigate the effects of circuit resistance training (CRT) on post-exercise appetite and energy intake in chronic hemiparetic stroke patients. A secondary aim was to evaluate the reproducibility of these effects. Methods: Seven participants met the eligibility criteria and, in a randomized order, participated in a non-exercise control session (CTL) and two bouts of CRT. The CRT involved 10 exercises with 3 sets of 15-repetition maximum per exercise, performed using a vertical loading approach, with each set interspersed with 45s of walking. Expired gases were carried out to calculate the net energy cost of the exercise and the relative energy intake post-CTL/CRT. Hunger, fullness, desire to eat, and energy intake were assessed at baseline and for 12 h after CTL and CRT. Results: Compared to CTL, hunger, desire to eat (P < .001), and relative energy intake (P < .05) were significantly lower after CRT, whereas the perception of fullness was significantly higher (P < .001). Significant differences between CTL and CRT were observed only for the first 9 h of the post-exercise period for hunger, fullness, and desire to eat (P < .05). No significant differences in appetite or relative energy intake were observed between the two bouts of CRT. Conclusions: A bout of CRT elicited decreased post-exercise appetite and relative energy intake in chronic hemiparetic stroke patients. Decreased appetite perceptions lasted for around 9 h and were reproducible.
... In fact, patients with diabetes are 2-4 times more likely to suffer from cardiovascular disease than healthy people [10] . Therefore, the formulation of sports rehabilitation programs for this part of the population needs to pay more attention to the above contents, individualized exercise rehabilitation programs [11] . For example, for patients who lack exercise, avoid directly engaging in unaccustomed strenuous physical exertion and high competitive exercise, advocate proper warm-up and post-exercise stretching exercise, and emphasize strict compliance with the prescribed target heart rate and a more cautious "progressive transitional exercise program." ...
Preprint
Exercise rehabilitation is an important part in the comprehensive management of patients with diabetes and there is a need to conduct comprehensively evaluation of several factors such as the physical fitness, cardiovascular risk and diabetic disease factors. However, special disease features of diabetes and its wide heterogeneity make it difficult to apply individualized approaches. In this study, a novel framework was established based on the Fuzzy Analytic Hierarchy Process (FAHP) approach to calculate various physiological factors weights when developing a diabetic exercise prescription. Proposed factors were investigated with respect to three groups which contains 12 different aspects. The relative weights were assessed by a database which established through a questionnaire survey. It is concluded that the physical fitness factors and cardiovascular risk factors need to be paid more attention to considered in the formulation of exercise rehabilitation programs than disease factors. And the cardiopulmonary function of physical fitness factors accounts for the highest importance. Furthermore, it was found that blood lipids have the lowest importance among studied factors. The mathematical model of exercise rehabilitation program for diabetes patients was established, which provided the theoretical basis for individualized guidance of exercise rehabilitation program.
... Aerobic exercise (AE) is an effective treatment for many systemic diseases especially chronic diseases [7]. Currently, animal studies have shown that 8 weeks of AE increases tear secretion in diabetic mice [8]. ...
Article
Full-text available
Background To study the effects of aerobic exercise (AE) on tear secretion and tear film stability in dry eye patients. Methods This study consisted of two parts, each part included 3 groups, namely dry eye without AE group, dry eye with AE group and pre-clinical dry eye with AE group. In part 1, we studied the variations of Schirmer I test and six tear compositions before and after AE (34 eyes in each group). In part 2, we studied the variations of tear meniscus height, first and average non-invasive tear breakup time (F-NITBUT and A-NITBUT), lipid layer thickness, number of incomplete and complete blinks, partial blink rate (PBR) and visual acuity before and after AE (30 eyes in each group). Results In dry eye with AE group, Schirmer I test at 0 min after AE increased significantly compared to baseline (P < 0.001), the oxidative stress marker 8-hydroxy-2′-deoxyguanosine after AE decreased significantly compared to baseline (P = 0.035, P = 0.045), F-NITBUT and A-NITBUT after AE prolonged significantly compared to baseline (P < 0.001, P = 0.007, P = 0.036; P < 0.001, P = 0.001, P = 0.044), number of incomplete blinks and PBR at 10 min after AE decreased significantly compared to baseline (P < 0.001; P < 0.001) while number of complete blinks increased significantly (P < 0.001). Besides, significant differences were also found between dry eye with AE group and dry eye without AE group at all above corresponding time point (P < 0.05). Conclusion AE promotes tear secretion and improves tear film stability in dry eye patients. AE may be a potential treatment for dry eye. Trial registration Chinese Clinical Trial Registry, ChiCTR2000038673. Registered 27 September 2020
... [23][24][25] For these reasons, when stroke patients maintained an upright posture, anteroposterior and left-right asymmetry and altered physical structure led to ankle dysfunction and instability, and these problems caused ADL impairments. 26 In this study, after using the VSE, we observed an increase in static balance ability. These results are consistent with Jain & Shah. ...
Article
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Although many studies have focused on balance exercises for elderly or stroke patients, no comprehensive studies have investigated the use of training on different surfaces (TDS) with analysis of gait performance in elderly male stroke patients. The active properties of balance and subjective reporting of functional gait ability were used to identify the effects of TDS. Static balance (SB), dynamic balance (DB) and gait analysis was measured in 30 elderly stroke patients. The patients were divided into the TDS group (n=15) and a control group (CG, n=15). Fifteen elderly stroke patients underwent TDS five times a week for 12 weeks. The data was analyzed using repeated measures analysis of variance. Significant differences were observed between the two groups (TDS and Control): SB (p < 0.0001), DB (OSI: p < 0.0001, APSI: p < 0.001, MLSI: p < 0.004) and gait analysis (right: temporal step time: p < 0.0001, temporal cycle time: p < 0.001, temporal double support time: p < 0.0001; left: temporal step time: p < 0.0001, temporal cycle time: p < 0.0001, temporal double support time: p < 0.0001). TDS in elderly male stroke patients suggests that the characteristics of gait performance in these patients may be improved by increasing static balance, dynamic balance and gait velocity. It is hoped that the results of this trial will provide new information on the effects of TDS on balance stability and gait ability in stroke patients, through changes in stability of the lower extremities. Level III, Case-control Study. Keywords: Static Balance; Dynamic Balance; Gait analysis; Stroke; Hemiplegia
... Aerobics (AE) is outlined as "designed or constructed repetitive physical activity for long durations and at sufficient intensity to improve physical fitness." It is proposed that AE be picked up on most days of the week at intensity that gradually increased for at least eight weeks [5]. Aerobics (AE) incorporated into post-stroke rehabilitation programs greatly improves function and prevent repeated strokes. ...
Article
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Background: Stroke is one of the world's leading causes of death and long-term lack of ability. Objectives: This study aimed to test the effect of aerobic versus anaerobic exercise on stroke patients' quality of life. Methods: Thirty male patients with stroke enrolled in this study. The patients were divided into three groups at random: two research groups (GA) and (GB) and one control group (GC). A traditional physical-therapy program was provided for the control group (GC) including: Passive Range of motion exercises for tightens muscles, Facilitation for weak muscles through: PNF technique, quick stretching. Besides traditional physical therapy, an aerobic exercise was performed by the patients in a study group (GA). Other than traditional physical treatment, patients received anaerobic training in the study group (GB). The session time for each group was 50-60 min; it is conducted three times a week for eight weeks. The Outcome Measures: The Arabic version of a short form dimension test (SF-36) used to assess the QOL items of the SF-36 were divided into eight different domains. All groups were evaluated before and after intervention with a QOL questionnaire (SF36). Results: There was a statistical meaningful increase in physical functioning, (vitality) energy/fatigue, emotional well-being, social functioning, pain and general-health in study groups (GA), (GB) compared with that of control group (GC) after therapy. However, there was no significant difference between groups in role limitations due to physical health and role limitations due to emotional problems. There was no meaningful difference in the quality of life items within groups (GA), (GB) after therapy. Conclusion: Eight weeks of training revealed non-significant difference between aerobic and anaerobic groups. However, either aerobic or anaerobic training has a beneficial effect on quality of life in stroke patients.
... From the perspective of recognition object, it includes routine aerobics action collection [1], aerobics type algorithm recognition, and aerobics action judgment. In the conventional method of Aerobics action recognition, generally through the analysis of data sets and the in-depth study of the key characteristics of calisthenics movements, the recognition and cognition of movement judgment can be realized [2]. e core content of the aerobics action automatic recognition system is to identify the accuracy and efficiency in the process of aerobics action recognition, which is of great significance to promote the intelligent development of the combination of pyramid algorithm application optimization and convolution neural network deep learning [3]. ...
Article
Full-text available
In order to realize high-accuracy recognition of aerobics actions, a highly applicable deep learning model and faster data processing methods are required. Therefore, it is a major difficulty in the field of research on aerobics action recognition. Based on this, this paper studies the application of the convolution neural network (CNN) model combined with the pyramid algorithm in aerobics action recognition. Firstly, the basic architecture of the convolution neural network model based on the pyramid algorithm is proposed. Combined with the application strategy of the common recognition model in aerobics action recognition, the traditional aerobics action capture information is processed. Through the characteristics of different aerobics actions, different accurate recognition is realized, and then, the error of the recognition model is evaluated. Secondly, the composite recognition function of the convolution neural network model in this application is constructed, and the common data layer effect recognition method is used in the optimization recognition. Aiming at the shortcomings of the composite recognition function, the pyramid algorithm is used to improve the convolution neural network recognition model by deep learning optimization. Finally, through the effectiveness comparison experiment, the results show that the convolution neural network model based on the pyramid algorithm is more efficient than the conventional recognition method in aerobics action recognition.
... Strength, aerobic and functional exercise interventions are known to improve mobility, reduce physiological risk profiles and enhance participation for at least five years beyond the onset of stroke (D'Isabella et al., 2017;Poltawski et al., 2015;Saunders et al., 2016;Young et al., 2019). Supporting PwS to transition from rehabilitation services into longer term exercise programmes has been identified as a priority within published guidelines (MacKay-Lyons et al., 2020;Royal College of Physicians, 2016). Purposed services and venues that specifically target the needs of PwS are limited (Schouten et al., 2011) and the need for closer partnerships between health care and community wellness programmes has been identified (Miller et al., 2019). ...
Article
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Purpose Seated Power Assisted Exercise (PAE) equipment is an accessible exercise mode for people with limited mobility following stroke and is available at a small number of community-based venues. The purpose of this qualitative study was to understand the lived experience of using PAE amongst PwS in a community venue and identify recommendations for the development and advancement of PAE equipment. Method Semi-structured interviews were conducted with 8 participants (PwS) attending a community stroke venue where PAE equipment was available. Transcribed data were analysed using interpretative phenomenological analysis. Results Three overarching themes emerged from the analysis; 1) Don’t tell me I’ve plateaued; 2) PAE facilitates the transition into long-term recovery; 3) Reframing the experience of stroke. Participants associated the uptake of PAE alongside venue membership as a turning point in their adjustment to life following stroke. In addition, recommendations for future development of the equipment were identified. Conclusion These findings indicate that membership of a stroke venue alongside engagement with PAE facilitated transition from early stroke rehabilitation into longer term recovery. The results of this study have informed the need for future product design and highlighted PAE is an effective mode for continued rehabilitation in third-sector services.
Article
Introduction Stroke survivors struggle to meet clinical recommendations for physical exercise duration and intensity. During the past two decades, emerging evidence has shown effectiveness of music interventions for several motor tasks in stroke rehabilitation. Additionally, music has been found effective for increasing exercise performance in athletes and clinical populations. It is postulated that the therapeutic effects of music in physical exercise are modulated by preference and task-specificity of the music. Methods We tested this hypothesis in a pilot study using a three-arm randomized cross-over design comprising the following auditory conditions during cycle ergometry cardiorespiratory exercise sessions: (a) a group-tailored music playlist, (b) radio music, and (c) a non-music control condition. Participants (n = 19) were inpatient stroke survivors undergoing rehabilitation between 2 and 12 weeks post infarct. Results Our results demonstrate that clinical characteristics are an important determinant for identifying patients who can benefit from music. Specifically, participants with a higher level of gait functioning experienced no benefit, whereas participants with a low level of gait functioning showed an increase in both exercise duration (M = 4.46 minutes) and time spent in the recommended heart rate intensity (M = 6.39 and M = 2.49 minutes for the playlist and radio condition, respectively). Discussion The findings suggest a beneficial role of music in rehabilitation of stroke patients with low gait functioning. Future studies should ultimately disentangle which musical parameters are more likely to induce the putative ergogenic effects. Trial registry number: NCT05398575.
Article
Background There are multiple stroke guidelines globally. To synthesize these and summarize what existing stroke guidelines recommend about the management of people with stroke, the World Stroke Organisation (WSO) Guideline committee, under the auspices of the WSO, reviewed available guidelines. They identified areas of strong agreement across guidelines, and their global coverage.AimsTo systematically review the literature to identify stroke guidelines (excluding primary stroke prevention and subarachnoid haemorrhage) since 1st January 2011, evaluate quality (AGREE II), tabulate strong recommendations, and judge applicability according to stroke care available (minimal, essential, advanced).Summary of reviewSearches identified 15400 titles, 911 texts were retrieved, 203 publications scrutinized by the three subgroups (acute, secondary prevention, rehabilitation), and recommendations extracted from most recent version of relevant guidelines. For acute treatment, there were more guidelines about ischaemic stroke than intracerebral haemorrhage; recommendations addressed pre-hospital, emergency, and acute hospital care. Strong recommendations were made for reperfusion therapies for acute ischaemic stroke. For secondary prevention, strong recommendations included establishing aetiological diagnosis, management of hypertension, weight, diabetes, lipids, lifestyle modification; and for ischaemic stroke: management of atrial fibrillation, valvular heart disease, left ventricular and atrial thrombi, patent foramen ovale, atherosclerotic extracranial large vessel disease, intracranial atherosclerotic disease, antithrombotics in non-cardioembolic stroke. For rehabilitation there were strong recommendations for organized stroke unit care, multidisciplinary rehabilitation, task specific training, fitness training, and specific interventions for post-stroke impairments.Most recommendations were from high income countries, and most did not consider comorbidity, resource implications and implementation. Patient and public involvement was limited.Conclusions The review identified a number of areas of stroke care in there was strong consensus. However there was extensive repetition and redundancy in guideline recommendations. Future guidelines groups should consider closer collaboration to improve efficiency, include more people with lived experience in the development process, consider comorbidity, and advise on implementation.
Article
Lay Summary Research has demonstrated that both exercise, and a reduction in cardiovascular disease (CVD) risk factors (i.e., high blood sugar, blood lipids, and blood pressure), following a stroke or transient ischemic attack (TIA) are beneficial for reducing risk of recurrent stroke or TIA and for improving overall quality of life. Despite this evidence, many stroke and TIA survivors remain inactive and sedentary and present with multiple CVD risk factors. The purpose of this commentary is to highlight gaps in the current literature in regard to exercise and behavior interventions for the stroke and TIA populations, present ideas for intervention design, and discuss the dissemination and implementation of research findings. The future research ideas presented in this commentary are based on current research findings, as well as the professional experience of the article authors. Professional experience spans occupational therapy in neurorehabilitation, clinical exercise physiology in rehabilitation, creation and implementation of stroke rehabilitation clinics, stroke and TIA research, and behavioral and implementation science.
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Introduction Moderate intensity continuous training (MICT) is usually recommended for stroke or transient ischemic attack (TIA) patients. High intensity interval training (HIIT) has emerged as a potentially effective method for increasing cardiorespiratory fitness (CRF) among clinical populations. Its effectiveness remains to be demonstrated after stroke. A combined program of HIIT and MICT was designed to create a realistic exercise program implemented for a clinical setting to help patients become more active. Purpose This study aimed to compare the effects of a 6-month exercise program with either MICT only or a combination of HIIT and MICT and a control group in terms of CRF, cardiovascular risk factors, functionality, cognitive function (Montreal Cognitive Assessment) and depression markers (Hospital Anxiety and Depression Scale). Methods This randomized controlled trial started with 52 participants (33 men and 19 women, mean age: 69.2 ± 10.7) divided into three groups: HIIT + MICT combined, MICT, and control. Both exercise groups consisted of 4 weekly sessions including supervised and at-home exercise. Outcomes were assessed at T0 (baseline measure), T6 (end of exercise protocols), and T12 (follow-up), 40 participants having completed the 12-month follow-up. Results At T6, both HIIT+MICT and MICT programs provided a similar increase of CRF (3 ml·min-1·kg-1) from baseline ( p < 0.01), while the control group showed a global slight decrease. Despite some decrease of CRF at T12 compared to T6, improvement persisted 6 months post-intervention (HIIT + MICT: p < 0.01 and MICT: p < 0.05). The control group decreased compared with baseline ( p < 0.05). The two exercise programs induced a comparable increase in self-reported physical activity and a decrease in anxiety and depression markers. Participants in HIIT + MICT and MICT programs declared a good degree of acceptability assessed by the Acceptability and Preferences Questionnaire. Conclusion A 6-month HIIT + MICT combined program and a standard MICT program induced similar improvements in CRF, self-reported physical activity and anxiety and depression markers among patients with prior ischemic stroke or TIA compared with a control group. These effects appear to persist over time. Addition of HIIT was safe and considered acceptable by participants. Our results do not support any superiority of the combination HIIT + MICT nor disadvantage vs. MICT in this population.
Article
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Power assisted exercise equipment designed to assist multi-directional movements represent an exercise solution for people with stroke. Users identified digitization of the equipment through a new Graphical User Interface (GUI) to display feedback on exercise performance as a development priority. The Medical Device Technology (MDT) framework was adopted to structure the four-stage digitization programme and ensure meaningful user involvement. This paper reports on stage two of the digitization programme, the aim of which was to create a prototype GUI. Storyboarding followed by participatory data analysis was selected as a co-design method to engage professional (n = 6) and expert (n = 8) end users to create artefacts and express preferences relevant to the design of the GUI. Four overarching themes emerged from thematic analysis of the data; (a) aesthetic format, (b) functional features, (c) exercise programme, (d) motivation and reward. The data was crystallized with external sources to generate a design criterion matrix which directed the first iteration of the prototype GUI. Storyboarding with participatory analysis was an effective method for engaging participants in the design of the GUI and associated user experience. This paper represents a novel application of storyboarding to the MDT framework in user centred digital design.
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The problem In the field of upper limb neurorehabilitation, the translation from research findings to clinical practice remains troublesome. Patients are not receiving treatments based on the best available evidence. There are certainly multiple reasons to account for this issue, including the power of habit over innovation, subjective beliefs over objective results. We need to take a step forward, by looking at most important results from randomized controlled trials, and then identify key active ingredients that determined the success of interventions. On the other hand, we need to recognize those specific categories of patients having the greatest benefit from each intervention, and why. The aim is to reach the ability to design a neurorehabilitation program based on motor learning principles with established clinical efficacy and tailored for specific patient's needs. Proposed solutions The objective of the present manuscript is to facilitate the translation of research findings to clinical practice. Starting from a literature review of selected neurorehabilitation approaches, for each intervention the following elements were highlighted: definition of active ingredients; identification of underlying motor learning principles and neural mechanisms of recovery; inferences from research findings; and recommendations for clinical practice. Furthermore, we included a dedicated chapter on the importance of a comprehensive assessment (objective impairments and patient's perspective) to design personalized and effective neurorehabilitation interventions. Conclusions It's time to reconcile research findings with clinical practice. Evidence from literature is consistently showing that neurological patients improve upper limb function, when core strategies based on motor learning principles are applied. To this end, practical take-home messages in the concluding section are provided, focusing on the importance of graded task practice, high number of repetitions, interventions tailored to patient's goals and expectations, solutions to increase and distribute therapy beyond the formal patient-therapist session, and how to integrate different interventions to maximize upper limb motor outcomes. We hope that this manuscript will serve as starting point to fill the gap between theory and practice in upper limb neurorehabilitation, and as a practical tool to leverage the positive impact of clinicians on patients' recovery.
Article
Introduction: Aerobic exercise training after stroke has positive effects on quality of life, motor recovery, and aerobic endurance. The aim of this study was to investigate the effectiveness of anti-gravity treadmill gait training and underwater walking therapy on cardiorespiratory fitness, gait and balance in stroke survivors. Methods: The study included 39 patients with a history of stroke who were admitted to our center between July 2017 and January 2018. The patients were randomly assigned to anti-gravity treadmill training, underwater walking therapy, or a control group. The aerobic capacity of the participants was evaluated with the 6-min walk test and cycle ergometer testing before and after the treatment. Balance was examined using the Berg Balance Scale (BBS). Results: There was a statistically significant increase from pre- to post-treatment with regard to maximum heart rate and length of walking distance during 6-min walk test parameters in patients who underwent anti-gravity treadmill training (p < 0.05). The cycle ergometer training results showed significant improvements compared to baseline after treatment in patients who underwent anti-gravity training in terms of maximum heart rate attained during exercise stress testing, time to complete the test, rates of metabolic equivalents of task scores and peak oxygen consumption (p < 0.05). Improvements were also observed in ventricular repolarization indices including corrected QT intervals (QTc), Tp-e interval and Tp-e/QT, Tp-e/QTc ratio in the anti-gravity group (p < 0.05). BBS results showed no statistically significant difference in all groups (p > 0.05). Conclusion: The data of this study showed that anti-gravity treadmill training has favorable effects on cardiorespiratory fitness in stroke survivors.
Article
Background and purpose: Regular, sustained moderate-to-vigorous physical activity (MVPA) is a recommended strategy to reduce the risk of recurrent stroke for people who have had transient ischemic attack (TIA) or mild stroke. This study aimed to explore attitudes toward, and experience of engaging in physical activity by adults following a TIA or mild stroke. Methods: Constructivist grounded theory methodology informed data collection and analysis. Interviews from 33 adults with TIA or mild stroke (mean age 65 [SD 10] years, 48% female, 40% TIA) were collected. Results: Business as usual characterized physical activity engagement post-TIA or mild stroke. Most participants returned to prestroke habits, as either regular exerciser or nonexerciser, with only a small number making changes. Influencing factors for physical activity participation included information, challenges, strategies, and support. Business as usual was associated with a perceived lack of information to suggest a need to change behaviors. Nonexercisers and those who decreased physical activity emphasized challenges to physical activity, while regular exercisers and those who increased physical activity focused on strategies and support that enabled participation despite challenges. Discussion and conclusion: Information about the necessity to engage in recommended physical activity levels requires tailoring to the needs of the people with TIA or mild stroke. Helpful information in combination with support and strategies may guide how to navigate factors preventing engagement and might influence the low level of physical activity prevalent in this population.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A376).
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Hypoxia preconditioning is neuroprotective, but the therapeutic effects of intermittent hypoxia were not fully considered. The present study investigated the neuroprotective effect and mechanism of intermittent hypoxia on motor function after cerebral ischemia and explored alternative clinical treatment options. In total, 36 8-week-old male Sprague-Dawley rats were subjected to 60 min of transient middle cerebral artery occlusion (tMCAO) and then randomly divided into a sham-operated group (SHAM), tMCAO-sedentary group (SED), and tMCAO-intermittent hypoxia group (IH). The intervention was performed 1 week after tMCAO and lasted 4 weeks. Rats in the IH group were placed in an animal hypoxic chamber (altitude 5000 m and oxygen concentration of 13%) for 4 h/day and 7 days/week, and rats in the SED group were placed in a normoxic environment for 4 weeks. Body weights, neurological deficit scores, cerebral infarction volume ratios, gait analyses, mitochondrial structure, adenosine triphosphate (ATP) content and AMO-activated protein kinase (AMPK), peroxisome proliferator-activated receptor γ co-activator-1α (PGC-1α), and silencing regulatory protein 3 (Sirt3) expression in the peri-ischemic region brain tissues were detected during the intervention. Compared with the SED group, the body weight of the IH group gradually recovered, and the neurological deficit scores were significantly reduced ( P < 0.05). The gait analysis results showed that the pressure of the affected paw and the maximum content area, swing speed, stride length, and other parameters were significantly restored ( P < 0.05). The cerebral infarction volume ratio was significantly reduced ( P < 0.01). Mitochondrial morphological structure damage in the peri-ischemic region brain tissues recovered, the number was significantly increased ( P < 0.05), and the expression of AMPK, PGC-1α, and Sirt3 proteins ( P < 0.05), and ATP content were significantly increased ( P < 0.05). Intermittent hypoxia may activate the AMPK–PGC-1α–Sirt3 signaling pathway, promote mitochondrial biogenesis, repair mitochondrial ultrastructural damage, and improve mitochondrial function to reduce brain damage and promote motor function recovery in rats with cerebral ischemia.
Chapter
Stroke is a major cause of disability in adults. Exercise is critical during the acute, subacute, and chronic phases of stroke management. The benefits of exercise for stroke survivors include improved function, and a reduction in secondary consequences, such as recurrent stroke and falls. However, many people with stroke are inactive and face barriers to participation in regular exercise. Trained health professionals should work collaboratively with stroke patients to develop a program that is individually tailored to the person’s stroke-related impairments, level of function, and personal preferences. Care must also be taken to ensure communication and cognitive impairments are appropriately catered for, and strategies to manage post-stroke fatigue need to be considered. In the early phases of recovery, there is a period of enhanced neural plasticity. During this time, task-specific training conducted under the supervision of appropriately qualified health professionals is critical to optimize recovery of function. Aerobic, strength, and balance exercises may be performed at all stages of post-stroke recovery and can improve fitness, reduce disability risk of recurrent stroke and falls risk. While exercise is generally safe for stroke survivors, specific care should be taken to minimize risk of falls and musculoskeletal injury. The identification of individual barriers to exercise and the development of strategies to overcome modifiable barriers are likely to increase uptake of programs and longer term adherence. Strategies that facilitate participation in exercise, such as the utilization of social supports and mechanisms for monitoring and feedback (e.g., using activity monitors or diaries), should be incorporated into every program.
Article
Introduction: Limited data exist regarding the effects of acute exercise and exercise training on cerebrovascular hemodynamic variables post-stroke. Purpose: This systematic review and meta-analysis 1) examined the effects of acute exercise and exercise training on cerebrovascular hemodynamic variables reported in the stroke exercise literature; and 2) synthesized the peak middle cerebral artery blood velocity (MCAv) achieved during an acute bout of moderate-intensity exercise in individuals post-stroke. Methods: Six databases (MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, AMED) were searched from inception to December 1st 2021, for studies that examined the effect of acute exercise or exercise training on cerebrovascular hemodynamics in adults post-stroke. Two reviewers conducted title and abstract screening, full-text evaluation, data extraction, and quality appraisal. Random effects models were used in meta-analysis. Results: Nine studies, including 4 acute exercise (n=61) and 5 exercise training studies (n=193), were included. Meta-analyses were not statistically feasible for several cerebrovascular hemodynamic variables. Descriptive analysis reveals that exercise training may increase cerebral blood flow and cerebrovascular reactivity to carbon dioxide among individuals post-stroke. Meta-analysis of three acute exercise studies revealed no significant changes in MCAv during acute moderate intensity exercise (n=48 participants, mean difference = 5.2 cm/s, 95% CI [-0.6, 11.0], P=0.08) compared to resting MCAv values. Conclusion: This review suggests that individuals post-stroke may have attenuated cerebrovascular hemodynamics as measured by the MCAv during acute moderate-intensity exercise. Higher quality research utilizing agreed upon hemodynamic variables are needed to synthesize the effects of exercise training on cerebrovascular hemodynamics post-stroke.
Article
Objective Best practice guidelines recommend that aerobic exercise (AEx) be implemented as early as possible poststroke, yet the prescription of AEx remains limited in stroke rehabilitation settings. This study used theoretical frameworks to obtain an in-depth understanding of barriers and enablers to AEx implementation in the stroke rehabilitation setting. Methods A qualitative, descriptive study was conducted. Participants were recruited from 4 stroke rehabilitation settings in Ontario, Canada, that have participated in an implementation study to provide structured AEx programming as part of standard care. Six clinician focus groups (with 19 physical therapists and 5 rehabilitation assistants) and one-to-one interviews with 7 managers and 1 physician were conducted to explore barriers and enablers to AEx implementation. The Theoretical Domains Framework (TDF) and Consolidated Framework for Implementation Research (CFIR) informed content analysis for clinician and manager perspectives, respectively. Results Barriers specific to resource constraints and health care system pressures, combined with patient goals, led to interventions to improve function being prioritized over AEx. Successful implementation was enabled through an interprofessional approach and team engagement in the planning and implementation process. Health care providers described concerns about patient safety, but confidence and capability for implementing AEx were enabled by education, skill development, use of exercise tests, and consultation with individuals with content expertise. Participants described the development of supportive processes that enabled AEx implementation within team workflows and shared resources. Conclusion Strategies to support implementation of AEx in stroke rehabilitation should incorporate knowledge and skills; the provision of clinical decision-making tools; access to expert consultation; the roles and social influence of the interprofessional team and formal and informal leaders; and supportive processes adapted to the local context. Impact Results from this study will inform the development of a clinical implementation toolkit to support clinical uptake of AEx in the stroke rehabilitation setting.
Objectives To compare five distinct methods to score the peak of oxygen consumption (VO2peak) obtained through the cardiopulmonary exercise testing (CPET) in individuals after stroke. Materials and methods The VO2peak was obtained through the CPET with five methods: method-1: the highest value of the test; method-2: the highest value of the last 30 seconds at peak exercise; method-3: the mean of the last 30 seconds at peak exercise; method-4: the mean of the last 20 seconds at peak exercise; method-5: the highest value averaged of the 3 last blocks of 10 seconds at peak exercise. The coefficient of variance (CV) and the mean differences with 95% confidence interval (CI) between the scoring methods were calculated. A post-hoc test (Tukey HSD) was performed to calculate the adjusted 95%CI. Results Fifty-nine individuals were included (54±12 years, 56±60 months after stroke). The CV of the methods 1-to-5 were, respectively: 27.91%, 25.77%, 23.38%, 23.83%, and 23.33%. There was no difference between method-1 and method-2 (95%CI: -1.10 to 4.69) and between methods 3 to 5: method-3 and method-4 (95%CI: -2.97 to 2.82); method-3 and method-5 (95%CI: -3.57 to 2.22); method-4 and method-5 (95%CI: -3.49 to 2.30). However, method-1 and -2 provided VO2peak values different from that of methods 3-to-5. Conclusions The scoring method of obtaining the VO2peak has an influence on its magnitude. Since methods 3-to-5 showed lower CV and provided similar values, they should be used to calculate the VO2peak obtained through the CPET in individuals after stroke.
Article
Objective: to investigate, in individuals after stroke, the concurrent validity of the Human Activity Profile (HAP) to provide the VO2peak and the construct validity of the HAP to assess exercise capacity; and to provide equations based upon the HAP outcomes to estimate the distance covered in the Incremental Shuttle Walking Test (ISWT). Design: Cross-sectional study. Setting: University laboratory. Participants: Fifty-seven individuals (54±11 years) after stroke. Intervention: Not applicable. Main outcome measures: Agreement between the VO2peak provided by the HAP (lifestyle energy consumption (LEC) outcome, in mL.kg⁻¹.min⁻¹) and the gold standard measure of the VO2peak (mL.kg⁻¹.min⁻¹), obtained through the symptom-limited Cardiopulmonary Exercise Test (CPET). Correlation between the HAP outcomes (LEC; the maximum activity score (MAS) and the adjusted activity score (AAS)) and the construct measure: the distance covered (in meters) in the ISWT. An equation to estimate the distance covered in the ISWT was determined. Results: High magnitude agreement was found between the VO2peak, in mL.kg⁻¹.min⁻¹, obtained by the symptom-limited CPET and the value of VO2peak, in mL.kg⁻¹.min⁻¹, provided by the HAP (LEC) (ICC=0.75;p<0.001). Low to moderate magnitude correlations were found between the distance covered in the ISWT and the HAP (LEC/MAS/AAS) (0.34≤rho≤0.58). The equation to estimate the distance covered in the ISWT explained 31% of the variability of the ISWT (ISWTestimated=-361.91+(9.646xAAS)). Conclusion: The HAP questionnaire is a clinically applicable way to provide a valid value of VO2peak (in mL.kg⁻¹.min⁻¹) and to assess the exercise capacity of individuals after stroke. Furthermore, an equation to estimate the distance covered in the submaximal field exercise test (ISWT) based on the result of the AAS (in points) was provided.
Article
Background The numerous barriers to community-based physical activity programs have been exacerbated by the COVID-19 pandemic, especially among individuals with disabilities. eHealth programs may provide an alternative approach to address the physical activity needs of stroke survivors, but little is known about their feasibility or acceptance. Objective The aims of this study were to 1) evaluate the feasibility of a remotely supervised home-based group eHealth program called Fitness and Mobility Exercise (FAME@home); 2) explore the influence of FAME@home on physical condition, mobility, self-efficacy, depression and anxiety; and 3) describe participants’ satisfaction and experiences. Methods A pre-post pilot study was used to recruit stroke survivors (>1 y post stroke) to complete a 12-week (2 days/week) eHealth program in small groups (n = 3). Feasibility indicators were assessed for process (e.g. inclusion criteria), resources (e.g. ability to use technology), management (e.g. major challenges), and treatment (e.g. influence on clinical outcomes and adverse events). Results Nine participants were recruited with a mean (SD) of 60 (13) years of age and 7 (4) years post-stroke; eight completed the program. FAME@home was feasible for indicators of process, management, and treatment. Minor considerations to improve resources were suggested (i.e. support for technology use). There were statistically significant improvements in mobility after completion of FAME@home and 100% of the participants reported satisfaction. No adverse events occurred. Conclusion FAME@home was feasible to deliver as a remotely supervised group exercise program to community-dwelling stroke survivors, with high levels of retention and adherence. FAME@home improved accessibility to exercise and facilitated engagement by having a class schedule and social interaction.
Article
Background Stroke survivors do not meet physical activity (PA) recommendations to accrue the associated health benefits. Perceived barriers and motivators to PA can be influenced by geographic and cultural nuances that are important to consider when developing stroke-specific PA interventions. Objective The objectives of this study were to describe PA duration and frequency, barriers and motivators to PA, and to explore sex and ages differences in PA among stroke survivors in Quebec. Methods A cross-sectional online survey was used to recruit Quebecers through special interest groups and word-of-mouth who experienced a stroke (≥18y, ≥1y post-stroke). Twenty-one survey items were related to demographic information, PA behavior, barriers and motivators to PA, and physical inactivity. Summary statistics were calculated using SPSS. Results Thirty individuals who were 7.6 ± 8.3 years post-stroke completed the survey. Light intensity aerobic PA was reported by 97% of participants, moderate intensity PA by 70%, high intensity by 30%, and 37% reported doing strength training. Barriers to PA were fear of falling (47%), not feeling comfortable participating in PA at a gym (33%) and lack of energy (30%), while motivators included, improving physical condition (87%), feeling good (67%) and reducing risk of subsequent stroke (70%). Conclusion Our findings show that 30 stroke survivors from Quebec did not achieve the minimal PA recommendations. Alternative approaches to PA should consider accessibility, safety, and enhancing fitness to optimize PA participation for stroke survivors living in Quebec.
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People who have had a transient ischemic attack (TIA) or mild stroke have a high risk of recurrent stroke. Secondary prevention programs providing support for meeting physical activity recommendations may reduce this risk. Most evidence for the feasibility and effectiveness of secondary stroke prevention arises from programs developed and tested in research institute settings with limited evidence for the acceptability of programs in ‘real world’ community settings. This qualitative descriptive study explored perceptions of participation in a secondary stroke prevention program (delivered by a community-based multidisciplinary health service team within a community gym) by adults with TIA or mild stroke. Data gathered via phone-based semi-structured interviews midway through the program, and at the end of the program, were analyzed using constructivist grounded theory methods. A total of 51 interviews from 30 participants produced two concepts. The first concept, “What it offered me”, describes critical elements that shape participants’ experience of the program. The second concept, “What I got out of it” describes perceived benefits of program participation. Participants perceived that experiences with peers in a health professional-led group program, held within a community-based gym, supported their goal of changing behaviour. Including these elements during the development of health service strategies to reduce recurrent stroke risk may strengthen program acceptability and subsequent effectiveness.
Article
Attention-deficit/hyperactivity disorder (ADHD) is the most prevalent neurodevelopmental disorder in children, and it's linked to a higher risk of academic failure, interpersonal issues, mental illness, and criminality. Despite several of the comparative and detailed reviews on the effects of ADHD interventions on core symptoms, there is no data summarizing the effects of aerobic exercise (AE) on executive functions (EFs). Therefore, this study aimed to systematically review and determine the relationship between AE (acute and chronic) dosage and EFs (attention, inhibition, set-shifting, and working memory) in youth with ADHD. The consideration of how AE dosage impacts aspects of EFs has not been investigated in detail previously. The study adhered to PRISMA guideline. Sixdatabases were searched without any date restrictions, up to February 2021, for articles relating to AE interventions to influence EFs in youth with ADHD≤18 years old. Quality assessment of the reviewed papers was addressed. Thirteen studies met the inclusion criteria. Improvements in all aspects of EFs were reported after children with ADHD engaged in acute AE lasting 20-30 minutes with at least moderate intensity (65% ≤ 80% HRmax).Furthermore, chronic exercise that lasts at least 45 minutes and in the range of moderate tohigh intensity (i.e., 60% ≤ 75% HRmax), 3 days/week for 6-12, elicits additional benefits in inhibition and set-shifting.Different dosage of AE might differently influence aspects of EFs; however, this finding rests on preliminary evidence at this stage and thus should be treated with caution.It is necessary to establish suitable interventions with regard to the dosage of AE types to improve EFs in young people with ADHD.
Article
Background: Hypertension is highly prevalent in stroke patients and reducing blood pressure is a priority. Aerobic exercise is known to induce postexercise hypotensive responses, but limited studies have documented this concept in stroke patients. The purpose was to investigate the effect of a single bout of moderate intensity continuous training (MICT) and high-intensity interval training (HIIT) on postexercise ambulatory blood pressure with patients with prior ischemic stroke or transient ischemic attack (TIA). Methods: Ten hypertensive adults (mean age: 70±9 years) with prior ischemic stroke or TIA participated using a randomized crossover design. Ambulatory blood pressure was monitored for up to 8 hours after either ergocycle MICT or HIIT of respectively 50% and 95% of peak power output. Blood pressure was compared to pre-exercise resting measure. Results: HIIT and MICT induced a decrease of systolic blood pressure of -11.0±9.2 mmHg and -4.7±4.5 mmHg respectively (P=0.03) immediately after the exercise. Ambulatory systolic blood pressure showed a steady linear increase (R2=0.90; P<0.001) of ~1.2 mmHg/hour and returned to pre-exercise measure after 8 hours. Effect of the two exercise conditions over time did not significantly differ (P=0.278). Diastolic blood pressure was not affected by both exercises. Conclusions: Those results suggest that HIIT induce a systolic blood pressure reduction of greater magnitude than MICT immediately after cycling exercise among patients with prior ischemic stroke or TIA. For both exercises, effects on ambulatory blood pressure are similar and persist up to 8 hours.
Article
Objective To determine the relationship between physical activity and mortality in community-dwelling stroke survivors. Methods The Canadian Community Health Survey was used to obtain self-reported physical activity (PA) across four survey cycles and was linked to administrative databases to obtain prior diagnosis of stroke and subsequent all-cause mortality. PA was measured as metabolic equivalents (METs) per week and meeting minimal PA guidelines was defined as 10 MET-hours/week. Cox proportional hazard regression models and restricted cubic splines were used to determine the relationship between PA and all-cause mortality in respondents with prior stroke and controls, adjusting for sociodemographic factors, co-morbidities, and functional health limitations. Results The cohort included 895 respondents with prior stroke and 97805 controls. Adhering to PA guidelines was associated with lower hazard of death for those with prior stroke (adjusted hazard ratio [aHR] 0.46, 95% CI 0.29-0.73) and controls (aHR 0.69, 95% CI 0.62-0.76). There was a strong dose-response relationship in both groups, with a steep early slope and the vast majority of associated risk reduction occurring between 0 and 20 MET-hours/week. In the group of stroke respondents, PA was associated with greater risk reduction in those <75 years of age (aHR 0.21, 95% CI 0.10-0.43) compared to those > 75 years of age (aHR 0.68, 95% CI 0.42-1.12). Conclusions PA was associated with lower all-cause mortality in an apparent dose-dependent manner among those with prior stroke, particularly in younger stroke survivors. Our findings support efforts towards reducing barriers to PA and implementation of PA programs for stroke survivors in the community. Classification of Evidence This study provides Class IV evidence that in community-dwelling survivors of stroke, adhering to physical activity guidelines was associated with lower hazard of death.
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Background Power assisted exercise is accessible and acceptable for people with stroke. The potential for technological advancement of the equipment to improve the user experience has been identified. Involvement of end users and service providers in the design of health technologies is essential in determining how said technology is perceived and adopted. This project invited people with stroke and service providers to influence design features and determine machine selection in the preliminary stages of a codesign research programme. Aims To capture the perspectives of people with stroke and professionals working with people with stroke about proposed digitalisation of power assisted exercise equipment and select machines for prototype development. Methods Nominal group technique was used to capture the perspectives, ideas, preferences and priorities of three stakeholder groups: people with stroke, rehabilitation professionals and exercise scientists. Two questions underpinned the structure of the events; ‘What does an assistive exercise machine need to do to allow the person with stroke to engage in exercise?’ and ‘Which machines would you prioritise for use with PwS?’ Attendees were invited to cast votes to indicate their preferred machines. Findings Synthesis of the data from the NGT identified four domains; software and interface, exercise programme, machine and accessories, setting and service. Three preferred machines from a range of nine were identified through vote counting. Conclusion Nominal group technique enabled a structured approach to patient and public involvement at the outset of a co-design project to advance rehabilitation technologies for people with stroke. Patient and service provider contribution The opinions and preferences of people with stroke, rehabilitation professionals and exercise scientists were central to key decisions which will shape the digitalisation of power assisted equipment, influence future research and guide implementation of the new technologies.
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Background This paper describes the initial development process of an eLearning continuing professional education program primarily for post-licensure physiotherapists –“Electronic Aerobic Exercise Recommendations to Optimize Best Practices in Care after Stroke” (eAEROBICS). Our objective was to develop an evidence-based, clinically relevant, user-friendly eLearning program for online delivery tailored to facilitate prescription of aerobic exercise post-stroke by physiotherapists. The Demand Driven Learning Model guided curriculum design, delivery, and evaluation. Based on previously identified gaps in physiotherapists’ knowledge of aerobic exercise, four learning modules were developed and delivered using an eLearning platform to maximize cost-effectiveness and flexibility. Five physiotherapists volunteered to pilot eAEROBICS, providing preliminary feedback on strengths and suggestions for improvement. Results Theoretical information and clinical applications addressed the learning objectives of each module in a logical manner. All technical or administrative issues encountered during program delivery were addressed. The feedback from the pilot end-users informed modifications to the eAEROBICS program. Conclusions Processes used in developing eAEROBICS have the potential to serve as a model of electronic continuing professional education for other areas of physiotherapy practice. Further investigation of end-user perspectives and clinical impact of the program is warranted to determine the overall effectiveness of the program.
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Background and Purpose Previous research suggests that patients receiving inpatient stroke rehabilitation are sedentary although there is little data to confirm this supposition within the Canadian healthcare system. The purpose of this cross-sectional study was to observe two weeks of inpatient rehabilitation in a tertiary stroke center to determine patients’ activity levels and sedentary time. Methods Heart rate (HR) and accelerometer data were measured using an Actiheart monitor for seven consecutive days, 24 h/day, on the second week and the last week of admission. Participants or their proxies completed a daily logbook. Metabolic equivalent (MET) values were calculated and time with MET < 1.5 was considered sedentary. The relationship between patient factors (disability, mood, and social support) and activity levels and sedentary time were analyzed. Results Participants (n = 19; 12 males) spent 10 h sleeping and 4 h resting each day, with 86.9% of their waking hours sedentary. They received on average 8.5 task-specific therapy sessions; substantially lower than the 15 h/week recommended in best practice guidelines. During therapy, 61.6% of physical therapy and 76.8% of occupational therapy was spent sedentary. Participants increased their HR about 15 beats from baseline during physical therapy and 8 beats during occupational therapy. There was no relationship between sedentary time or activity levels and patient factors. Discussion Despite calls for highly intensive stroke rehabilitation, there was excessive sedentary time and therapy sessions were less frequent and of lower intensity than recommended levels. Conclusions In this sample of people attending inpatient stroke rehabilitation, institutional structure of rehabilitation rather than patient-related factors contributed to sedentary time.
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On the basis of the GBD (Global Burden of Disease) 2013 Study, this article provides an overview of the global, regional, and country-specific burden of stroke by sex and age groups, including trends in stroke burden from 1990 to 2013, and outlines recommended measures to reduce stroke burden. It shows that although stroke incidence, prevalence, mortality, and disability-adjusted life-years rates tend to decline from 1990 to 2013, the overall stroke burden in terms of absolute number of people affected by, or who remained disabled from, stroke has increased across the globe in both men and women of all ages. This provides a strong argument that "business as usual" for primary stroke prevention is not sufficiently effective. Although prevention of stroke is a complex medical and political issue, there is strong evidence that substantial prevention of stroke is feasible in practice. The need to scale-up the primary prevention actions is urgent.
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Stroke rehabilitation is a progressive, dynamic, goal-orientated process aimed at enabling a person with impairment to reach their optimal physical, cognitive, emotional, communicative, social and/or functional activity level. After a stroke, patients often continue to require rehabilitation for persistent deficits related to spasticity, upper and lower extremity dysfunction, shoulder and central pain, mobility/gait, dysphagia, vision, and communication. Each year in Canada 62,000 people experience a stroke. Among stroke survivors, over 6500 individuals access in-patient stroke rehabilitation and stay a median of 30 days (inter-quartile range 19 to 45 days). The 2015 update of theCanadian Stroke Best Practice Recommendations: Stroke Rehabilitation Practice Guidelinesis a comprehensive summary of current evidence-based recommendations for all members of multidisciplinary teams working in a range of settings, who provide care to patients following stroke. These recommendations have been developed to address both the organization of stroke rehabilitation within a system of care (i.e., Initial Rehabilitation Assessment; Stroke Rehabilitation Units; Stroke Rehabilitation Teams; Delivery; Outpatient and Community-Based Rehabilitation), and specific interventions and management in stroke recovery and direct clinical care (i.e., Upper Extremity Dysfunction; Lower Extremity Dysfunction; Dysphagia and Malnutrition; Visual-Perceptual Deficits; Central Pain; Communication; Life Roles). In addition, stroke happens at any age, and therefore a new section has been added to the 2015 update to highlight components of stroke rehabilitation for children who have experienced a stroke, either prenatally, as a newborn, or during childhood. All recommendations have been assigned a level of evidence which reflects the strength and quality of current research evidence available to support the recommendation. The updated Rehabilitation Clinical Practice Guidelines feature several additions that reflect new research areas and stronger evidence for already existing recommendations. It is anticipated that these guidelines will provide direction and standardization for patients, families/caregiver(s), and clinicians within Canada and internationally.
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Despite the importance of regaining independent ambulation after stroke, the amount of daily walking completed during in-patient rehabilitation is low. The purpose of this study is to determine if (1) walking-related heart rate responses reached the minimum intensity necessary for therapeutic aerobic exercise (40%-60% heart rate reserve) or (2) heart rate responses during bouts of walking revealed excessive workload that may limit walking (>80% heart rate reserve). Eight individuals with subacute stroke attending in-patient rehabilitation were recruited. Participants wore heart rate monitors and accelerometers during a typical rehabilitation day. Walking-related changes in heart rate and walking bout duration were determined. Patients did not meet the minimum cumulative requirements of walking intensity (>40% heart rate reserve) and duration (>10 minutes continuously) necessary for cardiorespiratory benefit. Only one patient exceeded 80% heart rate reserve. The absence of significant increases in heart rate associated with walking reveals that patients chose to walk at speeds well below a level that has meaningful cardiorespiratory health benefits. Additionally, cardiorespiratory workload is unlikely to limit participation in walking. Measurement of heart rate and walking during in-patient rehabilitation may be a useful approach to encourage patients to increase the overall physical activity and to help facilitate recovery.
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Key points ► AGREE II (Appraisal of Guidelines, for Research, and Evaluation), which comprises 23 items and a user's manual, offers refinements of a new way to develop, report, and evaluate practice guidelines. ► Key changes from the original version include a new seven-point response scale, with modifications to half of the items, and a new user's manual. ► AGREE II is available online at the AGREE Research Trust website (www.agreetrust.org).
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To determine whether Adaptive Physical Activity (APA-stroke), a community-based exercise program for participants with hemiparetic stroke, improves function in the community. Nonrandomized controlled study in Tuscany, Italy, of participants with mild to moderate hemiparesis at least 9 months after stroke. Forty-nine participants in a geographic health authority (Empoli) were offered APA-stroke (40 completed the study). Forty-four control participants in neighboring health authorities (Florence and Pisa) received usual care (38 completed the study). The APA intervention was a community-based progressive group exercise regimen that included walking, strength, and balance training for 1 hour, thrice a week, in local gyms, supervised by gym instructors. No serious adverse clinical events occurred during the exercise intervention. Outcome measures included the following: 6-month change in gait velocity (6-Minute Timed Walk), Short Physical Performance Battery (SPPB), Berg Balance Scale, Stroke Impact Scale (SIS), Barthel Index, Hamilton Rating Scale for Depression, and Index of Caregivers Strain. After 6 months, the intervention group improved whereas controls declined in gait velocity, balance, SPPB, and SIS social participation domains. These between-group comparisons were statistically significant at P<.00015. Individuals with depressive symptoms at baseline improved whereas controls were unchanged (P<.003). Oral glucose tolerance tests were performed on a subset of participants in the intervention group. For these individuals, insulin secretion declined 29% after 6 months (P=.01). APA-stroke appears to be safe, feasible, and efficacious in a community setting.
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For people with disabilities, a physically active lifestyle can reduce the risk of secondary health problems and improve overall functioning. To determine the effects of the sport stimulation programme "rehabilitation and sports" (R&S) and R&S combined with the daily physical activity promotion programme "active after rehabilitation" (AaR) on sport participation and daily physical activity behaviour nine weeks after inpatient or outpatient rehabilitation. Subjects in four intervention rehabilitation centres were randomised to a group receiving R&S only (n = 315) or a group receiving R&S and AaR (n = 284). Subjects in six control rehabilitation centres (n = 603) received the usual care. Most common diagnoses were stroke, neurological disorders, and back disorders. Two sport and two daily physical activity outcomes were assessed with questionnaires seven weeks before and nine weeks after the end of rehabilitation. Data were analysed by intention to treat and on treatment multilevel analyses, comparing both intervention groups with the control group. The R&S group showed no significant change. Intention to treat analyses of the R&S+AaR group showed significant improvements in one sport (p = 0.02) and one physical activity outcome (p = 0.03). On treatment analyses in the R&S+AaR group showed significant improvements in both sport outcomes (p<0.01 and p = 0.02) and one physical activity outcome (p<0.01). Only the combination of R&S and AaR had increased sports participation and daily physical activity behaviour nine weeks after the end of inpatient or outpatient rehabilitation.
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Patients with stroke have elevated hemiparetic gait costs secondary to low activity levels and are often severely deconditioned. Decrements in peak aerobic capacity affect functional ability and cardiovascular-metabolic health and may be partially mediated by molecular changes in hemiparetic skeletal muscle. Conventional rehabilitation is time delimited in the subacute stroke phase and does not provide adequate aerobic intensity to reverse the profound detriments to fitness and function that result from stroke. Hence, we have studied progressive full body weight-support treadmill (TM) training as an adjunct therapy in the chronic stroke phase. Task-oriented TM training has produced measurable changes in fitness, function, and indices of cardiovascular-metabolic health after stroke, but the precise mechanisms for these changes remain under investigation. Further, the optimal dose of this therapy has yet to be identified for individuals with stroke and may vary as a function of deficit severity and outcome goals. This article summarizes the functional and metabolic decline caused by inactivity after stroke and provides current evidence that supports the use of TM training during the chronic stroke phase, with protocols and inclusion/exclusion criteria described. Our research findings are discussed in relation to associated research.
Article
Background: Levels of physical activity and physical fitness are low after stroke. Interventions to increase physical fitness could reduce mortality and reduce disability through increased function. Objectives: The primary objectives of this updated review were to determine whether fitness training after stroke reduces death, death or dependence, and disability. The secondary objectives were to determine the effects of training on adverse events, risk factors, physical fitness, mobility, physical function, health status and quality of life, mood, and cognitive function. Search methods: In July 2018 we searched the Cochrane Stroke Trials Register, CENTRAL, MEDLINE, Embase, CINAHL, SPORTDiscus, PsycINFO, and four additional databases. We also searched ongoing trials registers and conference proceedings, screened reference lists, and contacted experts in the field. Selection criteria: Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors. Data collection and analysis: Two review authors independently selected studies, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses and assessed the quality of the evidence using the GRADE approach. Diverse outcome measures limited the intended analyses. Main results: We included 75 studies, involving 3017 mostly ambulatory participants, which comprised cardiorespiratory (32 studies, 1631 participants), resistance (20 studies, 779 participants), and mixed training interventions (23 studies, 1207 participants). Death was not influenced by any intervention; risk differences were all 0.00 (low-certainty evidence). There were few deaths overall (19/3017 at end of intervention and 19/1469 at end of follow-up). None of the studies assessed death or dependence as a composite outcome. Disability scores were improved at end of intervention by cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% CI 0.19 to 0.84; 8 studies, 462 participants; P = 0.002; moderate-certainty evidence) and mixed training (SMD 0.23, 95% CI 0.03 to 0.42; 9 studies, 604 participants; P = 0.02; low-certainty evidence). There were too few data to assess the effects of resistance training on disability. Secondary outcomes showed multiple benefits for physical fitness (VO2 peak and strength), mobility (walking speed) and physical function (balance). These physical effects tended to be intervention-specific with the evidence mostly low or moderate certainty. Risk factor data were limited or showed no effects apart from cardiorespiratory fitness (VO2 peak), which increased after cardiorespiratory training (mean difference (MD) 3.40 mL/kg/min, 95% CI 2.98 to 3.83; 9 studies, 438 participants; moderate-certainty evidence). There was no evidence of any serious adverse events. Lack of data prevents conclusions about effects of training on mood, quality of life, and cognition. Lack of data also meant benefits at follow-up (i.e. after training had stopped) were unclear but some mobility benefits did persist. Risk of bias varied across studies but imbalanced amounts of exposure in control and intervention groups was a common issue affecting many comparisons. Authors' conclusions: Few deaths overall suggest exercise is a safe intervention but means we cannot determine whether exercise reduces mortality or the chance of death or dependency. Cardiorespiratory training and, to a lesser extent mixed training, reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve fitness, balance and the speed and capacity of walking. The magnitude of VO2 peak increase after cardiorespiratory training has been suggested to reduce risk of stroke hospitalisation by ˜7%. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription, the range of benefits and any long-term benefits.
Article
Introduction: Stroke is the leading cause of adult disability. Individuals poststroke possess less than half of the cardiorespiratory fitness (CRF) as their nonstroke counterparts, leading to inactivity, deconditioning, and an increased risk of cardiovascular events. Preserving cardiovascular health is critical to lower stroke risk; however, stroke rehabilitation typically provides limited opportunity for cardiovascular exercise. Optimal cardiovascular training parameters to maximize recovery in stroke survivors also remains unknown. While stroke rehabilitation recommendations suggest the use of moderate-intensity continuous exercise (MICE) to improve CRF, neither is it routinely implemented in clinical practice, nor is the intensity always sufficient to elicit a training effect. High-intensity interval training (HIIT) has emerged as a potentially effective alternative that encompasses brief high-intensity bursts of exercise interspersed with bouts of recovery, aiming to maximize cardiovascular exercise intensity in a time-efficient manner. HIIT may provide an alternative exercise intervention and invoke more pronounced benefits poststroke. Objectives: To provide an updated review of HIIT poststroke through ( a) synthesizing current evidence; ( b) proposing preliminary considerations of HIIT parameters to optimize benefit; ( c) discussing potential mechanisms underlying changes in function, cardiovascular health, and neuroplasticity following HIIT; and ( d) discussing clinical implications and directions for future research. Results: Preliminary evidence from 10 studies report HIIT-associated improvements in functional, cardiovascular, and neuroplastic outcomes poststroke; however, optimal HIIT parameters remain unknown. Conclusion: Larger randomized controlled trials are necessary to establish ( a) effectiveness, safety, and optimal training parameters within more heterogeneous poststroke populations; (b) potential mechanisms of HIIT-associated improvements; and ( c) adherence and psychosocial outcomes.
Article
Objective: This review aimed to investigate the effects of exercise-based interventions on cardiovascular risk factors in individuals with stroke or transient ischemic attack. Data sources: MEDLINE, EMBASE, PsycINFO, and CINAHL were searched from inceptions to 28 December 2016. Review methods: Randomized controlled trials were included that involved exercise with or without other interventions, included participants of any age, with diagnosis of transient ischemic attack or stroke, at any stage of severity or time period following the event, and reported cardiovascular risk factor outcomes. Review Manager (version 5.3) was used to aggregate data from all studies and from those involving only exercise interventions. Results: This review included 18 randomized controlled trials (930 participants) in the qualitative synthesis, 14 of which were included in the quantitative analysis (720 participants; ranging from 84 to 438 participants within individual meta-analyses). All interventions were effective in reducing resting systolic blood pressure (mean difference (MD): -5.32 mmHg, 95% confidence interval (CI): -9.46 to -1.18, P = 0.01), fasting glucose (MD: -0.11 mmol/L, 95% CI: -0.17 to -0.06, P < 0.0001), and fasting insulin (MD: -17.14 pmol/L, 95% CI: -32.90 to -1.38, P = 0.03), and increasing high-density lipoprotein cholesterol (MD: 0.10 mmol/L, 95% CI: 0.03-0.18, P = 0.008). Effects were maintained following meta-analysis of only exercise interventions. Conclusion: Findings suggest that exercise-based interventions are effective in reducing systolic blood pressure, fasting glucose, and fasting insulin, and increasing high-density lipoprotein cholesterol after stroke or transient ischemic attack, providing evidence for their implementation as a strategy for secondary prevention.
Article
Background and purpose: Best practice recommendations indicate that aerobic exercise (AEX) should be incorporated into stroke rehabilitation. However, this may be challenging in clinical settings. The purpose of this study was to assess physical therapist (PT) AEX prescription for patients with stroke, including AEX utilization, barriers to AEX prescription, dosing parameters, and safety considerations. Methods: A cross-sectional Web-based survey study was conducted. Physical therapists with valid e-mail addresses on file with the state boards of Florida, New Jersey, Ohio, Texas, and Wyoming were eligible to participate. Survey invitations were e-mailed to all licensed PT in these states. Analysis focused on respondents who were currently involved with clinical stroke rehabilitation in common practice settings. Results: Results from 568 respondents were analyzed. Most respondents (88%) agreed that AEX should be incorporated into stroke rehabilitation, but 84% perceived at least one barrier. Median prescribed AEX volume varied between practice settings from 20- to 30-minute AEX sessions, 3 to 5 days per week for 2 to 8 weeks. Prescribed intensity was most commonly light or moderate; intensity was determined by the general response to AEX and patient feedback. Only 2% of respondents reported that the majority of their patients with stroke had stress tests. Discussion and conclusions: Most US PTs appear to recognize the importance of AEX for persons poststroke, but clinical implementation can be challenging. Future studies and consensus are needed to clarify best practices and to develop implementation interventions to optimize AEX utilization in stroke rehabilitation.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, http://links.lww.com/JNPT/A167).
Article
Objective: To assess the influence of dosing parameters and patient characteristics on the efficacy of aerobic exercise (AEX) post-stroke. Data sources: A systematic review was conducted using Pubmed, MEDLINE, CINAHL, PEDro and Academic Search Complete. Study selection: Studies were selected that compared AEX to a non-aerobic control group among ambulatory persons with stroke. Data extraction: Extracted outcome data included: peak oxygen consumption during exercise testing (VO2peak), walking speed and walking endurance (6-minute walk test). Independent variables of interest were: AEX mode (seated or walking), AEX intensity (moderate or vigorous), AEX volume (total hours), stroke chronicity and baseline outcome scores. Data synthesis: Significant between-study heterogeneity was confirmed for all outcomes. Pooled AEX effect size estimates (AEX change - control change) from random effects models were: VO2peak, 2.2 mL/kg/min [95% CI: 1.3, 3.1]; walking speed, 0.06 m/s [95% CI: 0.01, 0.11]; and 6-minute walk test distance, 29 m [95% CI: 15, 42]. From meta-regression, greater VO2peak effect sizes were significantly associated with higher AEX intensity and higher baseline VO2peak. Greater effect sizes for walking speed and the 6-minute walk test were significantly associated with a walking AEX mode. In contrast, seated AEX did not have a significant effect on walking outcomes. Conclusions: AEX significantly improves aerobic capacity post-stroke, but may need to be task specific to impact walking speed and endurance. Higher AEX intensity is associated with better outcomes. Future randomized studies are needed to confirm these results.
Article
Purpose of review: Rehabilitation trials and postacute care to lessen impairments and disability after stroke, spinal cord injury, and traumatic brain injury almost never include training to promote long-term self-management of skills practice, strengthening and fitness. Without behavioral training to develop self-efficacy, clinical trials, and home-based therapy may fail to show robust results. Recent findings: Behavioral theories about self-management and self-efficacy for physical activity have been successfully incorporated into interventions for chronic diseases, but rarely for neurologic rehabilitation. The elements of behavioral training include education about the effects of practice and exercise that are relevant to the person, goal setting, identification of possible barriers, problem solving, feedback about performance, tailored instruction, decision making, and ongoing personal or social support. Mobile health and telerehabilitation technologies offer new ways to remotely enable such training by monitoring activity from wearable wireless sensors and instrumented exercise devices to allow real-world feedback, goal setting, and instruction. Summary: Motivation, sense of responsibility, and confidence to practice and exercise in the home can be trained to increase adherence to skills practice and exercise both during and after formal rehabilitation. To optimize motor learning and improve long-term outcomes, self-management training should be an explicit component of rehabilitation care and clinical trials.
Article
Background: The cardiorespiratory fitness of stroke survivors is low. Center-based exercise programs that include an aerobic component have been shown to improve poststroke cardiorespiratory fitness. This pilot study aims to determine the feasibility, safety, and preliminary efficacy of an individually tailored home- and community-based exercise program to improve cardiorespiratory fitness and walking capacity in stroke survivors. Methods: Independently ambulant, community-dwelling stroke survivors were recruited. The control (n = 10) and intervention (n = 10) groups both received usual care. In addition the intervention group undertook a 12-week, individually tailored, home- and community-based exercise program, including once-weekly telephone or e-mail support. Assessments were conducted at baseline and at 12 weeks. Feasibility was determined by retention and program participation, and safety by adverse events. Efficacy measures included change in cardiorespiratory fitness (peak oxygen consumption [VO2peak]) and distance walked during the Six-Minute Walk Test (6MWT). Analysis of covariance was used for data analysis. Results: All participants completed the study with no adverse events. All intervention participants reported undertaking their prescribed program. VO2peak improved more in the intervention group (1.17 ± .29 L/min to 1.35 ± .33 L/min) than the control group (1.24 ± .23 L/min to 1.24 ± .33 L/min, between-group difference = .18 L/min, 95% confidence interval [CI]: .01-.36). Distance walked improved more in the intervention group (427 ± 123 m to 494 ± 67m) compared to the control group (456 ± 101m to 470 ± 106m, between-group difference = 45 m, 95% CI: .3-90). Conclusions: Our individually tailored approach with once-weekly telephone or e-mail support was feasible and effective in selected stroke survivors. The 16% greater improvement in VO2peak during the 6MWT achieved in the intervention versus control group is comparable to improvements attained in supervised, center-based programs.
Article
Abstract Background Levels of physical fitness are low after stroke. It is unknown whether improving physical fitness after stroke reduces disability. Objectives To determine whether fitness training after stroke reduces death, dependence, and disability and to assess the effects of training with regard to adverse events, risk factors, physical fitness, mobility, physical function, quality of life, mood, and cognitive function. Interventions to improve cognitive function have attracted increased attention after being identified as the highest rated research priority for life after stroke. Therefore we have added this class of outcomes to this updated review. Search methods We searched the Cochrane Stroke Group Trials Register (last searched February 2015), the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1: searched February 2015), MEDLINE (1966 to February 2015), EMBASE (1980 to February 2015), CINAHL (1982 to February 2015), SPORTDiscus (1949 to February 2015), and five additional databases (February 2015). We also searched ongoing trials registers, handsearched relevant journals and conference proceedings, screened reference lists, and contacted experts in the field. Selection criteria Randomised trials comparing either cardiorespiratory training or resistance training, or both (mixed training), with usual care, no intervention, or a non-exercise intervention in stroke survivors. Data collection and analysis Two review authors independently selected trials, assessed quality and risk of bias, and extracted data. We analysed data using random-effects meta-analyses. Diverse outcome measures limited the intended analyses. Main results We included 58 trials, involving 2797 participants, which comprised cardiorespiratory interventions (28 trials, 1408 participants), resistance interventions (13 trials, 432 participants), and mixed training interventions (17 trials, 957 participants). Thirteen deaths occurred before the end of the intervention and a further nine before the end of follow-up. No dependence data were reported. Diverse outcome measures restricted pooling of data. Global indices of disability show moderate improvement after cardiorespiratory training (standardised mean difference (SMD) 0.52, 95% confidence interval (CI) 0.19 to 0.84; P value = 0.002) and by a small amount after mixed training (SMD 0.26, 95% CI 0.04 to 0.49; P value = 0.02); benefits at follow-up (i.e. after training had stopped) were unclear. There were too few data to assess the effects of resistance training. Cardiorespiratory training involving walking improved maximum walking speed (mean difference (MD) 6.71 metres per minute, 95% CI 2.73 to 10.69), preferred gait speed (MD 4.28 metres per minute, 95% CI 1.71 to 6.84), and walking capacity (MD 30.29 metres in six minutes, 95% CI 16.19 to 44.39) at the end of the intervention. Mixed training, involving walking, increased preferred walking speed (MD 4.54 metres per minute, 95% CI 0.95 to 8.14), and walking capacity (MD 41.60 metres per six minutes, 95% CI 25.25 to 57.95). Balance scores improved slightly after mixed training (SMD 0.27, 95% CI 0.07 to 0.47). Some mobility benefits also persisted at the end of follow-up. The variability, quality of the included trials, and lack of data prevents conclusions about other outcomes and limits generalisability of the observed results. Authors' conclusions Cardiorespiratory training and, to a lesser extent, mixed training reduce disability during or after usual stroke care; this could be mediated by improved mobility and balance. There is sufficient evidence to incorporate cardiorespiratory and mixed training, involving walking, within post-stroke rehabilitation programmes to improve the speed and tolerance of walking; some improvement in balance could also occur. There is insufficient evidence to support the use of resistance training. The effects of training on death and dependence after stroke are still unclear but these outcomes are rarely observed in physical fitness training trials. Cognitive function is under-investigated despite being a key outcome of interest for patients. Further well-designed randomised trials are needed to determine the optimal exercise prescription and identify long-term benefits.
Article
Purpose: This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. Methods: Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. Results: Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. Conclusions: The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.
Article
Background and purpose: Although aerobic exercise (AE) has been shown to improve aerobic capacity and reduce morbidity in neurological populations, its application is challenging. The purpose of this study was to survey Canadian physical therapists practicing in adult neurorehabilitation regarding the use of AE in clinical practice. Methods: Members of the Neurosciences Division of the Canadian Physiotherapy Association were invited to participate in a Web-based survey. Results: Response rate was 36% (N = 155) with every Canadian province represented. The majority of respondents were females in full-time practice for more than 15 years. The majority (88%) agreed/strongly agreed with the following: "AE should be incorporated into treatment programs of patients with neurological conditions." Although 77% prescribed AE, barriers to use included patient concerns (cardiac status, cognitive/perceptual deficits, fatigue) and operations (lack of staff, time, screening tools). The most commonly used screening tools were health records and patient responses to exercise and the least common was exercise stress tests. Overground walking and cycle ergometry were the most frequently used AE modes, and general response to exercise and patient feedback were most frequently used for determining exercise intensity and monitoring AE. Discussion and conclusions: Respondents clearly recognized the importance of AE in neurorehabilitation. Barriers to application of AE and limitations in the use of appropriate screening and training procedures need to be addressed to advance clinical utilization of AE in neurological practice. Understanding current patterns of utilization of AE is important for the development of professional education initiatives and clinical guidelines for best practices in AE for neurological populations. Video Abstract available (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A40) for more insights from the authors.
Article
To describe the barriers to implementation of evidence-based recommendations (EBRs) for stroke rehabilitation experienced by nurses, occupational therapists, physical therapists, physicians and hospital managers. The Stroke Canada Optimization of Rehabilitation by Evidence project developed EBRs for arm and leg rehabilitation after stroke. Five Canadian stroke inpatient rehabilitation centers participated in a pilot implementation study. At each site, a clinician was identified as the "local facilitator" to promote the 6-month implementation. A research coordinator observed the process. Focus groups done at completion were analyzed thematically for barriers by two raters. A total of 79 rehabilitation professionals (23 occupational therapists, 17 physical therapists, 23 nurses and 16 directors/managers) participated in 21 focus groups of three to six participants each. The most commonly noted barrier to implementation was lack of time followed by staffing issues, training/education, therapy selection and prioritization, equipment availability and team functioning/communication. There was variation in perceptions of barriers across stakeholders. Nurses noted more training and staffing issues and managers perceived fewer barriers than frontline clinicians. Rehabilitation guideline developers should prioritize evidence for implementation and employ user-friendly language. Guideline implementation strategies must be extremely time efficient. Organizational approaches may be required to overcome the barriers. [Box: see text].
Article
Cardiorespiratory fitness programs are increasingly used in stroke rehabilitation. Maximal oxygen uptake is the gold standard measurement of cardiorespiratory fitness; however, no recent publications have collated evidence about maximal oxygen uptake levels following stroke. We therefore performed a systematic review of maximal oxygen uptake in stroke survivors, aiming to observe changes in levels over time, and associations with severity of stroke. We searched Medline and Embase until April 2011, and included cross-sectional studies, longitudinal studies, and baseline data from intervention trials. Studies had to recruit at least 10 stroke survivors, and report direct measurement of maximal/peak oxygen uptake. We then compared maximal oxygen uptake with published data from age and gender-matched controls. The search identified 3357 articles. Seventy-two full texts were retrieved, of which 41 met the inclusion criteria. Time since stroke ranged from 10 days to over seven-years. Peak oxygen uptake ranged from 8 to 22 ml/kg/min, which was 26-87% of that of healthy age- and gender-matched individuals. Stroke severity was mild in most studies. Three studies reported longitudinal changes; there was no clear evidence of change in peak oxygen uptake over time. Most studies recruited participants with mild stroke, and it is possible that cardiorespiratory fitness is even more impaired after severe stroke. Maximal oxygen uptake might have been overestimated, as less healthy and older stroke survivors may not tolerate maximal exercise testing. More studies are needed describing mechanisms of impaired cardiorespiratory fitness and longitudinal changes over time to inform the optimal 'prescription' of cardiorespiratory fitness programs for stroke survivors.
Article
Exercise testing is a valuable tool in the management of pediatric patients with heart disease. It can be used to help determine the need for medical or surgical interventions and can be used to determine the efficacy of these interventions. Common settings in which exercise testing may be helpful include evaluation of exercise tolerance in repaired or unrepaired congenital heart disease, assessment of heart failure symptoms, diagnosis and management of dysrhythmias, determination of cardiac, as opposed to respiratory causes of chest pain and prescription of exercise rehabilitation programs. This manuscript will review the indications, techniques, and uses of exercise stress testing in the pediatric population with an emphasis on the development of the exercise physiology lab as a source of high-quality data that can be used to improve patient outcomes.
Article
This chapter describes the system used by the American College of Chest Physicians to grade recommendations for antithrombotic and thrombolytic therapy as part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Clinicians need to know if a recommendation is strong or weak, and the methodologic quality of the evidence underlying that recommendation. We determine the strength of a recommendation by considering the balance between the desirable effects of an intervention and the undesirable effects (incremental harms, burdens, and for select recommendations, costs). If the desirable effects outweigh the undesirable effects, we recommend that clinicians offer an intervention to typical patients. The uncertainty associated with the balance between the desirable and undesirable effects will determine the strength of recommendations. If we are confident that benefits do or do not outweigh harms, burden, and costs, we make a strong recommendation in our formulation, Grade 1. If we are less certain of the magnitude of the benefits and risks, burden, and costs, and thus their relative impact, we make a weaker Grade 2 recommendation. For grading methodologic quality, randomized controlled trials (RCTs) begin as high-quality evidence (designated by "A"), but quality can decrease to moderate ("B"), or low ("C") as a result of poor design and conduct of RCTs, imprecision, inconsistency of results, indirectness, or a high likelihood for reporting bias. Observational studies begin as low quality of evidence (C) but can increase in quality on the basis of very large treatment effects. Strong (Grade 1) recommendations can be applied uniformly to most patients. Weak (Grade 2) suggestions require more judicious application, particularly considering patient values and preferences and, when resource limitations play an important role, issues of cost.
Article
One of the major consequences after stroke is the deterioration in health-related quality of life (HRQOL). Three previous systematic reviews indicated that exercise has limited to no effect in improving HRQOL in stroke survivors. The objective of this meta-analysis was to update the evidence on exercise and HRQOL in stroke survivors with additional new information on randomized controlled trials that have been published since these 3 previous reviews. MEDLINE, Cumulated Index to Nursing and Allied Health Literature, EMBASE, and SportsDiscus databases were searched for randomized controlled trials reporting the effects of exercise on HRQOL in stroke survivors from 1950 to March 2010. The methodological quality of each study was appraised using the Physiotherapy Evidence Database scale. Standardized mean difference was used to compute effect size and subgroup analysis was conducted to test the consistency of results across the subgroups with different characteristics. A total of 1101 citations was identified and 9 studies met all criteria for a total sample of 426 stroke survivors. Eight studies were rated as good quality (ie, Physiotherapy Evidence Database scale ≥5). This meta-analysis provided evidence that exercise can have a small to medium effect on HRQOL outcomes (standardized mean difference, 0.32, P<0.01) at postintervention but not at follow-up after exercise was terminated (standardized mean difference, 0.17, P=0.12). No adverse events related to exercise were reported. The results provide moderate support for the use of exercise to improve HRQOL in stroke survivors. However, the challenge for researchers is identifying effective strategies for sustaining these effects postintervention.